Sergio Zamboni

Serum uric acid shows a J-shaped trend with coronary mortality in non-insulin-dependent diabetic elderly people. The CArdiovascular STudy in the ELderly (CASTEL).

The relationship between serum uric acid (SUA) and risk of coronary heart disease (CHD) mortality remains controversial, particularly in diabetic subjects. The aim of the present study is to evaluate whether SUA independently predicts CHD mortality in non-insulin-dependent elderly people from the general population and to investigate the interactions between SUA and other risk factors. Five hundred and eighty-one subjects aged ≥65 years with non-insulin-dependent diabetes mellitus were prospectively studied in the frame of the CArdiovascular STudy in the ELderly (CASTEL). Historical and clinical data, blood tests and 12-year fatal events were recorded. SUA as a continuous item was divided into tertiles and, for each tertile, adjusted relative risk (RR) with 95% confidence intervals (CI) was derived from multivariate Cox analysis. CHD mortality was predicted by SUA in a J-shaped manner. Mortality rate was 7.9% (RR 1.28, CI 1.05–1.72), 6.0% (reference tertile) and 12.1% (RR 1.76, CI 1.18–2.27) in the increasing tertiles of SUA, respectively, without any difference between genders. In diabetic elderly subjects, SUA independently predicts the risk of CHD mortality in a J-shaped manner.

Hyperthyroidism as a Cause of Pulmonary Arterial Hypertension: A Prospective Study:

The authors assessed the prevalence of pulmonary arterial hypertension (PAH) in patients with hyperthyroidism and evaluated the response to treatment of the thyrotoxicosis. They assessed the pulmonary artery systolic pressure (PASP) at rest (estimated by echocardiography) in 23 consecutive patients diagnosed with hyperthyroidism due to Graves’ disease or toxic multinodular goiter. Twelve of 23 patients (52%) did not show antithyroglobulin and antithyroperoxidase antibodies. Seventeen patients were followed up for at least 9 months after achieving a stable euthyroid status. Fifteen (65%) patients demonstrated PAH at admission. Four patients were lost to follow-up; therefore they were able to evaluate 17 patients serially with echocardiography. Sixteen patients normalized their PASP value: 13 after methimazole, 2 after total thyroidectomy, and 1 after 131I treatment. In 1 patient no significant change in PASP was observed. This patient experienced an acute myocardial reinfarction during follow-up. They found a higher prevalence than that previously reported in observational studies. In addition, they demonstrated that the PAH reverses after correction of hyperthyroidism. Elevated PASP at rest on echocardiography may be considered a frequent finding of thyrotoxicosis. Moreover, the data seem not to support an autoimmune pathogenesis for PAH.

Body Mass Index and Mortality in Elderly Men and Women from General Population

Background: The role of body mass index (BMI) as a factor influencing longevity of the elderly subject is still under debate. Objective: To evaluate at a population level whether or not BMI is a risk factor of mortality in the elderly, highlighting possible gender-related differences. Methods: 3,282 subjects aged 65–95 years, were recruited from an Italian general population and 12-year events were recorded. Blood tests and anthropometric measurements were performed. BMI as a continuous item was divided into quintiles and, for each quintile, adjusted hazard ratio (HR) with 95% confidence intervals for mortality was derived by classes of age and gender from Cox analysis. Results: BMI inversely predicted overall and cancer mortality in men only. Overall mortality rate was 64.7% (HR = 1.63 [1.23–2.71]) in the 1st quintile of BMI, 54.9% (1.21 [0.92–1.73]) in the 2nd, 54.1% (1.20 [0.85–1.67]) in the 3rd, 53.3% (1.04 [0.82–1.32]) in the 4th and 52.5% in the 5th; cancer mortality rate was 23.1% (HR = 2.35 [1.31–4.23]), 14.2% (HR = 1.19 [0.65–1.80]), 15.8% (HR = 1.49 [0.93–2.39]), 15.8% (HR = 1.36 [0.84–2.16]) and 13.4%, respectively. The relationship between BMI and mortality remained significant only in men aged 76 years or less. No relationship was found between BMI and coronary or cerebrovascular mortality. Conclusions: BMI <22.7 kg/m2 does not improve survival in the elderly, while it is an independent predictor of cancer mortality in men aged ≤76 years. No prediction based on BMI is possible in women.

Hashimoto's Thyroiditis and Graves' Disease Associated with Retroperitoneal Fibrosis

Retroperitoneal fibrosis is a rare disease of uncertain pathogenesis. However, its possible association with several immunopathologic conditions, the possibility of systemic involvement by the fibrous process, the presence of various autoantibodies, and the frequent response to immunosuppressive treatment all support an autoimmune pathogenesis. Riedels thyroiditis is a rare disease the pathogenesis of which is also thought to be immune-mediated based on its optimal response to steroids; Riedels thyroiditis is also frequently reported in association with retroperitoneal fibrosis. We describe here two cases of autoimmune thyroid disease associated with retroperitoneal fibrosis, the first with features of primary myxedema, the second of primary thyrotoxicosis. Histology of retroperitoneal fibrosis is documented and it is compatible with an immunopathologic condition. Thus, these two cases add further support to the hypothesis of an autoimmune pathogenesis of retroperitoneal fibrosis and indicate the importance of carefully monitoring for the development of other autoimmune disorders, i.e., of the thyroid gland, in patients with retroperitoneal fibrosis.

Co-existence of cutaneous T-cell lymphoma and B hairy cell leukemia.

A primary cutaneous form of peripheral T‐cell lymphoma (PTCL) and a low grade B‐cell non‐Hodgkins lymphoma that was classified as a variant of hairy cell leukemia (HCL) were simultaneously diagnosed in a 79‐year‐old woman by both phenotypic and genotypic analyses. The coexistence of a T‐ and B‐cell lymphoma in the same patient is rare, and, to our knowledge, this particular association has not been previously described. The patient was referred to our Department for evaluation of multiple cutaneous itchy, reddish plaques; laboratory analyses disclosed a lymphocytosis, that presented 6 years earlier. A bone marrow aspirate showed a 50% B‐cell interstitial infiltrate, while a skin biopsy surprisingly revealed a PTCL. Clonality of both neoplastic processes was assessed by Southern blot analysis. The indolent clinical course of the cutaneous disease, and the low and stable number of circulating neoplastic T cells supported the diagnosis of a mycosis fungoides (MF)‐like PTCL. Possible oncogenic events and/or putative underlying viral infections which could have played a role in the occurrence of B‐ and T‐cell non‐Hodgkins lymphomas in the same patient are discussed. Am. J. Hematol. 64:197–202, 2000.

Chronic obstructive pulmonary disease and cardiovascular mortality in elderly subjects from general population

Abstract Aims. To ascertain whether chronic obstructive pulmonary disease (COPD) is an independent risk factor for cardiovascular (CV) mortality in the elderly subjects from general population. Methods. 3282 subjects of the Northern Italy aged ≥65 years were followed up for 12 years in the frame of the CArdiovascular STtudy in the ELderly. Multivariate stepwise proportional hazard Cox regression was therefore used to identify the prognostic role of COPD on CV mortality in hypertensive (HT) and normotensive (NT) subjects. The hazard ratio (HR) of COPD with 95% confidence interval (CI) for mortality was adjusted for confounders in both genders. Results. COPD resulted to be an independent predictor of CV mortality (HR 1.34, CI 1.13–1.61) in HT but not in NT subjects. This was evident both in men (HR 1.44, 1.25–1.95) and women (HR 1.32, CI 1.14–1.53); pulse pressure (PP) was directly related and anti-hypertensive therapy inversely related to risk of CV mortality, an association that was greater in subjects with than without COPD. Conclusion. COPD should be included in the computation of global risk in HT subjects. PP is the main BP component in increasing CV risk in subjects with COPD. Controlled trials should be performed to evaluate the pressor targets to be reached in HT subjects with COPD, with the aim of decreasing their CV risk.

The e19a2 BCR/ABL fusion transcript with additional chromosomal aberrations on a new case of chronic myeloid leukemia (CML) of mild type.

The e19a2 BCR/ABL fusion transcript with additional chromosomal aberrations on a new case of chronic myeloid leukemia (CML) of mild type

Spontaneous Changes in Very High Blood Pressure after Admission to the Hospital and Their Relation to Target Organ Involvement

Spontaneous changes in blood pressure (BP) over a week after admission to the hospital were investigated in 127 patients admitted with diastolic BP at or above 120 mm Hg. Average BP decreased from 205/129 at admission to 174/110 on the 8th day. Regression analysis showed highly significant negative slopes which were related to initial levels but not to the presence or type of target organ involvement. After 1 week, 66% of the subjects attained a diastolic BP lower than 120 mm Hg. More remarkably, 36% attained values lower than 105 mm Hg: 33% of these had BP values less than 95 mm Hg. While not ruling out the importance of very high BP readings, it is concluded that they do not necessarily represent any pattern of either fixed or severe hypertension nor imply a need for urgent antihypertensive treatment.

Does treatment with olmesartan improve arterial stenoses due to fibromuscular dysplasia

Fibromuscular dysplasia (FMD) represents a group of non-atherosclerotic, non-inflammatory arterial diseases that most commonly involve renal and carotid arteries. Histological classification discriminates three main subtypes (intimal, medial and perimedial), which may be associated in the same patient. Although the etiology of FMD is not well understood, several mechanisms have been proposed, such as genetic predisposition, hormonal factors, paucity of vasa vasorum, repeated microtrauma, inadequate hormonal background, α-antitrypsin deficiency and arterial wall ischemia.1 The molecular biology of FMD is unclear. Pathology seems to be characterized by smooth muscle hyperplasia, elastic fiber destruction, fibrous tissue proliferation and arterial wall disorganization. Angiographic classification includes a multifocal type (with multiple stenoses) and the string-of-beads pattern (related to medial FMD), and tubular and focal types (which are not clearly related to specific histological lesions).

Internal carotid artery fibromuscular dysplasia in arterial hypertension: Management in clinical practice

Fibromuscular dysplasia (FMD) reminds of a rare form of secondary arterial hypertension occurring in young people and involving the renal arteries. FMD may also involve vertebral, subclavian, mesenteric, iliac arteries and carotid arteries. FMD of internal carotid arteries is a rare finding that is frequently incidental and asymptomatic. It usually occurs in middle‐aged women and is secondary to media‐intima fibrodysplasia. The carotid artery may be elongated or kinked and associated cerebral aneurysms have been reported. Symptoms including transient ischaemic attack or stroke are uncommon and are related to decrease of blood flow or embolization by platelet aggregates. At the onset, differential diagnosis with vasculitis must be placed. Computed tomography or magnetic resonance imaging (MRI) angiography demonstrates bilateral high‐grade stenosis with the characteristic “string of beads” pattern. Antiplatelet medication is the accepted therapy for asymptomatic lesions. Graduated endoluminal surgical dilation is an outmoded therapy, no longer used in most medical centres. Current percutaneous angioplasty is the preferred treatment for symptomatic carotid FMD, but no randomized controlled trials comparing this methodology with surgery is available. The management of a case of arterial systemic FMD in a 52‐year‐old women, diagnosed after a hypertensive crysis, is discussed. Imaging methods disclosed stenoses of carotid arteries, of celiac tripod and of superior mesenteric artery. Because of high risk associated to endovascular surgery, medical therapy was started. In the first year of follow‐up, no events have been reported.