Sabrina Arnone

Hemostatic function in young subjects with central obesity: relationship with left ventricular function.

This study was designed to evaluate coagulation and fibrinolysis activity and their relationship with left ventricular function in young obese subjects with central fat distribution. We assessed coagulation and fibrinolysis activity by evaluation of factor VII activity, fibrinogen and plasminogen, plasminogen activator inhibitor (PAI), and tissue plasminogen activator antigen basally (tPA1) and after venous occlusion (tPA2). These measures were evaluated in young (< 40 years) obese subjects with central fat distribution (n = 19) and in comparable lean subjects (n = 20). Blood glucose, triglycerides, total and high-density lipoprotein (HDL) cholesterol, apolipoprotein (apo) A1 and apo B, fasting immunoreactive insulin, and lipoprotein(a) levels were also measured by current methods. Left ventricular ejection fraction (LVEF) and peak filling rate (PFR) determined by radionuclide angiocardiography and left ventricular mass (LVM) and LVM indexed for body height (LVM/H) determined by echocardiographic study were calculated. Central obesity was evaluated by the waist to hip ratio (WHR) according to the criteria of the Italian Consensus Conference of Obesity. Factor VII (P < .001), fibrinogen (P < .001), plasminogen (P < .001), PAI activity (P < .001), tPA1 (P < .02), fasting blood glucose (P < .01), apo B (P < .02), and immunoreactive insulin (P < .01) were significantly higher in obese than in lean subjects. In contrast, HDL cholesterol (P < .01), tPA2 (P < .01), LVEF (P < .001), and PFR (P < .02) were significantly lower in obese than in lean subjects. In all subjects, WHR correlated directly with fibrinogen and inversely with tPA2; LVEF correlated inversely with tPA1, PAI, and fibrinogen; and PFR correlated inversely with factor VII activity.(ABSTRACT TRUNCATED AT 250 WORDS)

Echo-Doppler left ventricular filling abnormalities in patients with rheumatoid arthritis without clinically evident cardiovascular disease.

Our investigation aimed at verifying diastolic abnormalities in rheumatoid patients, without clinically evident cardiovascular disease and other confounding complaints, by using pulsed Doppler examination of transmitral blood flow. We selected 40 patients fulfilling revised American Rheumatism Association (ARA) criteria for the diagnosis of rheumatoid arthritis having no symptoms of cardiac disease or clinical findings of other extracardiac diseases. We also studied 40 rheumatoid‐matched healthy volunteers as a control group. An echocardiographic examination was carried out on each subject. Left ventricular structural and functional measurements were obtained. Interventricular septal thickness and left ventricular mass index were significantly higher in rheumatoid patients than in the control group. We also found in rheumatoid patients higher mean values of peak A velocity and A/E ratio. When multiple linear regression analysis was performed on the data of rheumatoid patients we found an independent relationship only between A/E ratio and left ventricular mass. In conclusion, our results confirm diastolic abnormalities in rheumatoid patients and point out that these abnormalities also affect echo‐Doppler parameters of left ventricular filling. Moreover, further analysis of our data may suggest the possibility that structural left ventricle changes could be responsible for left ventricular filling impairment.

Heredity and obesity-associated hypertension: impact of hormonal characteristics and left ventricular mass

Objectives: To investigate the influence of heredity on obesity-associated hypertension, we evaluated casual and 24-h blood pressure, left ventricular mass and some metabolic and hormonal measurements in normotensive obese subjects. Design: Healthy, normotensive obese subjects (n=81) with positive or negative family history of hypertension were studied. Both groups were also subdivided according to a positive or a negative family history of obesity. Accordingly, 45 obese subjects had a positive family history of hypertension, 25 of these having a positive (subgroup A) and 20 having a negative family history of obesity (subgroup B). The other 36 obese subjects had a negative family history of hypertension, 19 of these having a positive (subgroup C) and 17 having a negative family history of obesity (subgroup D). Methods: Casual and 24-h systolic (SBP), diastolic (DBP) and mean blood pressure (MBP) were evaluated. Serum fasting blood sugar, total cholesterol and triglycerides levels, urinary excretion of sodium, immunoreactive fasting insulin, plasma ANF levels, plasma renin activity (PRA), plasma aldosterone level, plasma adrenaline and noradrenaline levels and echocardiographic total left ventricular mass (LVM) and LVM: height ratio were also calculated. Results: Twenty-four-hour DBP, 24-h MBP, LVM, LVM:height ratio, total cholesterol and PRA values were significantly higher in normotensive obese offspring of hypertensive parents than in obese offspring of normotensive parents. Twenty-four-hour DBP and MBP, LVM, LVM:height ratio, insulin level, insulin:glucose ratio and PRA were significantly higher in subgroup A than in subgroup B. Fasting blood sugar level, 24-h DBP and MBP, insulin level, insulin:glucose ratio, PRA, noradrenaline, adrenaline and plasma aldosterone levels were significantly higher in subgroup C than in subgroup D. Multivariate analysis also indicated that 24-h MBP and PRA levels were significantly influenced by the association between a positive family history of hypertension and obesity. Conclusions: The present results suggest that a family history of obesity might increase the risk of developing hypertension in obese subjects. An elevated PRA may precede the development of hypertension in obese subjects who are at risk for developing hypertension.

Evidence-Based Knowledge Management: an approach to effectively promote good health-care decision-making in the Information Era

The sharing of information and the growth of knowledge together represent a foundation for the promotion of quality improvement of health care systems. This paper concerns knowledge, not only from an epistemological point of view, but also from a pragmatic one. In our paper, knowledge is discussed as the hub to promote better decision making and continuous professional development. Effective thinking is particularly needed. The critical point is to think about how health care systems can develop both an effective knowledge management network and how health-care organizations can actually be based on it. In this way, knowledge and knowledge hierarchy are defined according to Russel Achkoff’s vision. Generally, knowledge is crucial in decision-making, and Evidence-Based Medicine has its roots in knowledge. In particular, information management is the basis for a significant production of knowledge to promote good health-care decision-making. Thus, relationships between knowledge management and Evidence-Based Medicine are discussed, and a new paradigm is proposed: the Evidence-Based Knowledge Management. Finally, the role of Evidence-Based Knowledge Management within Clinical Governance is discussed together with some considerations about clinical governance implementation problems in Italy.

Sulodexide versus calcium heparin in the medium-term treatment of deep vein thrombosis of the lower limbs

Thirty adult patients with distal, monolateral deep vein thrombosis of the lower limbs were randomly treated for sixty days either with subcutaneous Ca-Heparin or with Sulodexide, administered IM for ten days and orally for fifty days. The thrombus accretion above the knee, the venous pressures of the affected leg, the clinical sympto matology, and some laboratory coagulative tests were monitored throughout the admin istration period. Local tolerability of the two treatments was also evaluated. The two applied treatments evidenced a net antithrombotic activity, preventing thrombus accretion above the knee, improving with the same efficacy the venous pressures in the affected legs, and similarly reducing clinical symptoms, with a quick and statistically significant trend toward normalization. Blood fibrinogen was significantly lowered by both drugs, while only Ca-heparin yielded a prolongation of activated partial thromboplastin time. Local tolerability of treatments was better for the mainly oral Sulodexide administrations, while subcutaneous Ca-heparin often induced small, though transient, hematomas.

Two-dimensional echocardiographic evaluation of left ventricular ejection fraction by the ellipsoid single-plane algorithm: a reliable method for assessing low or very low ejection fraction values?

The reliability of two-dimensional (2D) echocardiographic estimation of left ventricular ejection fraction (EF) is commonly recognized, but no satisfactory data are available about the accuracy of low or very low EF values determined by 2D echocardiography (ECHO-EF). The purpose of our study was to assess the reliability of low ECHO-EF values obtained using a simple time-economical algorithm such as the ellipsoid single-plane area-length method. Radionuclide angiography (RAD-EF) was taken as the standard of comparison. We studied 59 consecutive patients (31 women and 28 men) referred to our echocardiographic laboratory. Both 2D echocardiography and radionuclide angiography were blindly performed within 48 h of one another. EF was calculated by the two methods and then compared. Data were globally analyzed. Furthermore, data were divided and analyzed according to the ECHO-EF cut-off point of 50%. An ECHO-EF value of 50% was chosen to conventionally distinguish between low ECHO-EF values and normal-high ones. Data were plotted, and the line of equality and the regression lines were drawn. Regression line slopes, correlation coefficients, means and standard deviations were calculated. The agreement was analyzed by calculating the mean difference (RAD-EF-ECHO-EF) and the standard deviation of the differences. ECHO-EF was linearly related to RAD-EF even when data were split. In particular, as regards ECHO-EF < or = 50%, the regression line practically overlapped the line of equality, and the two methods showed both a strong correlation and a good degree of agreement.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgery during etanercept therapy in patients with rheumatoid arthritis: is it time to follow patient preferences?

Tumor necrosis factor (TNF)-a inhibitors, such as etanercept and infliximab, improve symptoms and function in patients affected by rheumatoid arthritis (RA) [1, 2] and, therefore, are playing an increasing role in the management of this disease. However, interference with endogenous TNF-a signalling has been reported to alter both normal inflammatory responses in tissue healing and infection surveillance [2, 3]. To our knowledge, the rates of surgery in RA are decreasing. However, with the duration of antiTNF therapy, the number of patients under these agents having surgery will be increasing. These data raise the question of whether TNF-inhibitors can be safely used in RA patients who should undergo surgery. The aim of the present paper was to discuss the effect of TNF-inhibitor use in RA patients undergoing surgery. A small cohort of patients undergoing different elective surgery while still on etanercept therapy in spite of physician advice was evaluated. Here, we report five cases selected from a large cohort of patients referred to the ‘‘Civico e Benfratelli’’ rheumatologic outpatient clinic (Table 1). The median duration of RA in the whole cohort was 10 years (range 1–23 years). The inclusion criterion was a history of elective surgery during etanercept therapy (25 mg twice weekly) started at least 12 months before surgery. All the assessed patients were on methotrexate (10–20 mg weekly) as diseasemodifying anti-rheumatic drug (DMARD) treatment and non-steroidal anti-inflammatory drugs or low-dose steroids for acute or sub-acute pain treatment.

A systematic approach to medical decision-making of uncommon clinical pictures: a case of ulcerative skin lesions by palm tree thorn injury and a one-year follow-up.

In clinical practice, the clinician is challenged with symptoms and/or signs at times apparently insoluble by diagnostic and/or therapeutic means. We propose that in these cases, we have to use an EBM approach in which evidence may be looked up in every available clinical report and bibliographic databases are used for searching that evidence. We report on a case of ulcerative skin lesions apparently insoluble by expert dermatologists following a conventional diagnostic and therapeutic process. We use this case report for illustrating a systematic approach to resolve diagnostic and therapeutic questions using a bibliographic database search (like MEDLINE and EMBASE). Both a systematic approach to bibliographic databases and a critically appraised topic on case reports (or case series) are needed to ‘rehabilitate’ low-level evidences (that is a case report or case series) to a higher level when we approach decision-making of uncommon clinical pictures. We demonstrate the possibility of using bibliographic databases to search and retrieve useful information for decision-making of uncommon clinical pictures. The method we have proposed can be applied in every area of the world, especially in rural areas. Finally, an Internet-shared database of uncommon clinical pictures with critically appraised topics could be useful in saving more time.