Susanna Gamberini

Temporal Patterns of Hospital Admissions for Transient Ischemic Attack: A Retrospective Population-based Study in the Emilia-Romagna Region of Italy:

Acute cerebrovascular events are not randomly distributed over time but show specific temporal patterns of occurrence. However, most studies focused stroke and little is known about transient ischemic attack. This study aimed to explore the existence of a temporal pattern of transient ischemic attack and the possible influence by the most common risk factors. The analysis included all hospital admissions with the ICD9-CM code for TIA, recorded in the database of the Emilia Romagna region of Italy (1998-2006; n = 43642, mean age 76.8 ± 11.5 years, 45.5% males). Transient ischemic attack was most frequent in autumn and winter and less common in spring and summer (P < 0.0001), with the highest number of cases in October and the lowest in February, and also most frequent on Monday (P < 0.0001). This study shows a seasonal and weekly pattern in occurrence of transient ischemic attack, independent of sex and the presence of the most common risk factors.

Takotsubo cardiomyopathy and acute infectious diseases: a mini-review of case reports.

Takotsubo cardiomyopathy (TTC), also defined as “stress cardiomyopathy,” is characterized by a systolic dysfunction localized in the apical and medial left ventricles. Takotsubo cardiomyopathy is more prevalent in females and it is usually related to an event triggered by physical or emotional stress. We systematically explored PubMed and Embase medical information source to identify case reports showing association between infection and TTC. For each kind of infection, we collected a set of data, including pathogen, site of infection, clinical outcome, patient age and sex, and author and year of publication. We found 26 articles dealing with 27 case reports (74% women). The mean age was 61.4 ± 13.7 years and bacterial infections were more frequent (n = 23, 85.2%). In 14 cases, there was a culture-based definition of the bacterial strain: gram+ in 8 cases (57.1%) and gram− in 6 cases (42.9%). Clinical outcome was always favorable.

Staphylococcus hemolyticus liver abscess as an uncommon presentation of silent colonic cancer: a case report.

To the Editor: Although liver abscess is a common intra-abdominal infection, accounting for about one of every 4,500 to 7,000 hospital admissions,1 the clinical manifestation of colonic cancer as a liver abscess, in the absence of liver metastases, is not frequent.

Not all acute lower back pain is benign—paravertebral abscess and colonic cancer

Low back pain with sciatica is one of the most common complaints of patients presenting to the ED, and it is usually managed on an outpatient basis. However, acute lower back pain not always derives from a benign cause. We report here the case of a 63-year-old diabetic man who presented to the ED complaining of acute low back pain with sciatica and fever. The cause was a large paravertebral abscess by Streptococcus milleri, and this was the first presenting sign of an unknown underlying colonic cancer.

Management of intradialytic hypertension: old problem, old drug?

Of the patients beginning with dialysis, 60–85% of them may account for hypertension, and dialysis alone is capable of controlling hypertension in over 50% of these patients [1]; resistant hypertension and paradoxical blood pressure (BP) elevation during dialysis are possible but relatively infrequent complications [1]. Nevertheless, there is no widely accepted definition of intradialytic hypertension [2]. Several definitions, mostly arbitrary, have been used such as any increase in mean arterial BP of 15 mmHg or more during or immediately after hemodialysis, hypertension during the second or third hour of dialysis after significant ultrafiltration has taken place, or an increase in BP that is resistant to ultrafiltration, with post-ultrafiltration BP exceeding the pre-ultrafiltration BP in more than half of the sessions [2]. Thus, the prevalence of intradialytic hypertension, in consideration with the different definitions, has shown wide variations, from 5 to 15% [2]. We report a case of a 70-year-old woman with a personal medical history including a long-standing smoking habit, type-2 diabetes mellitus with diabetic nephropathy, cerebral vascular disease, coronary artery disease, previous myocardial infarction treated with PTCA and stenting. Forty-one weeks before, she had started chronic dialysis therapy three times a week, performed by artero-venous fistula on an afternoon shift (13:00–18:00 hours). Some of the details of the dialysis treatment are bicarbonate dialysis, duration 3.5 h, average weekly body weight gain 3.3 kg, hourly decrease 9 mm Hg, blood flow 300 ml/min. Pharmacologic therapy included clopidogrel 75 mg/day, metoprolol 50 mg b.i.d., sustained-release isosorbide-5mononitrate 50 mg/day, nifedipine gastrointestinal therapeutic system (GITS) 60 mg/day, ramipril 10 mg/day, and clonidine transdermal (1 TTS1 system/week). The patient showed significant increase in BP levels, especially during the second hour of dialysis, not responding to several drug schedules, e.g., extradoses of nifedipine, amlodipine, and clonidine. Only the introduction in therapy of the vasodilatator minoxidil (Loniten , Pharmacia & Upjohn SpA) allowed a successful control and stabilization of the paradoxical BP increase (Table 1). A first point of discussion could be the lack of use of diuretics. In advanced renal failure, sodium imbalance is becoming positive, and the extracellular volume (ECV) expands. In patients with chronic kidney disease, especially in the case of poor adherence to salt restriction, diuretics play an important role [3]. However, this is not always the case for dialysis patients. The concept of controlling BP by achieving the lowest possible ECV has been termed as ‘‘dry weight’’, the post-dialysis weight at which the patient is and remains normotensive until the next dialysis despite the interdialytic fluid retention without anti-hypertensive medication [4]. Dry weight is usually assessed using the clinical method [4]. Useful information include: (1) medical history (dietary habits, salt excess) and presence/ absence of symptoms of volume overload; (2) clinical signs: blood pressure (measured lying, sitting, and standing), weight, central venous pressure, presence of edema; E. Rizzioli Modulo di Nefrologia, Unità Operativa di Medicina Interna, Ospedale del Delta, Azienda U.S.L. di Ferrara, Ferrara, Italy

An unusual cause of recurrent hemoptysis: tracheopatia osteoplastica

An otherwise healthy 55-year-old man was referred to the hospital by his general practitioner due to recurrent episodes of hemoptysis. His medical history was silent, although his working activity (textile branch) exposed him to organic dusts. Shortly after an acute bronchitis treated with aspirin, the patient had a first episode of hemoptysis. Even after aspirin withdrawal, thoracic sense of oppression and cough persisted for several days, and a second hemoptysis event occurred. Cardiothoracic physical examination was unremarkable, and his general practitioner performed electrocardiogram, chest X-ray, and blood chemistry panel (all these examinations were normal), and asked for cardiologic and otorhinolaryngoiatric consultations, with no findings of pathological remarks. Hemoptysis is a relatively common symptom of cardiopulmonary disease. Although bronchitis is a very common cause, a careful evaluation may be necessary to exclude more serious pathologic conditions, such as bronchogenic carcinoma and tuberculosis [1]. Moreover, the decision on whether to perform further investigations has not been influenced by the amount of bleeding. In fact, there is no correlation between quantity of blood and seriousness of the underlying thoracic disease [1]. In this case, given the patient’s age, his working history, the recurrence of hemoptysis episodes, and prior negative results, we decided not to dismiss hemoptysis as simply due to bronchitis, and proceed with a more advanced workup including CT scan and bronchoscopy. Thoracic high-resolution computerized tomography (HRCT) showed limited ‘‘polished glass’’ areas, localized to the posteriorbasal segments of inferior lobes. Bronchoscopy revealed the presence of multiple calcifications in the tracheobronchial cartilages, with normal mucosal surface, extending also to the larger bronchial ramifications and the carina (Fig. 1, upper and lower panels). Cultural examination and cytology of bronchoalveolar lavage were negative. The bronchoscopic picture was self-explaining, since the presence of sessile bony or cartilagineous nodules of the tracheal wall is the hallmark of tracheopatia osteoplastica. Tracheopatia osteoplastica (or tracheopatia osteochondroplastica) (TO) is an uncommon disease of the upper airways, characterized by the presence of multiple cartilaginous or bony projections into the tracheobronchial lumen [2]. It usually affects people aged [50 years, but incidence and prevalence in the general populations are unknown, since the great majority of cases are diagnosed only post-mortem [3]. The cause is unknown, and more often this disease is asymptomatic. However, the most frequent symptoms at presentation are chronic cough (54% of cases), sputum production (34%), and hemoptysis (20%) [2]. Computerized tomography may sometimes reveal tracheal soft tissue masses or beaded calcification in the tracheobronchial cartilages, although calcifications, luminal stenosis, wall thickening, and nodules need for differential diagnosis with other uncommon diseases involving the central airways, i.e., Wegener’s granulomatosis, relapsing polychondritis, amyloidosis, sarcoidosis, and tuberculosis. Thus, bronchoscopy remains the main diagnostic tool: nodules are most frequently distributed along the proximal tracheobronchial tree, especially in the upper and middle S. Savelli M. L. Grata A. Ricci S. Gamberini R. Manfredini (&) U.O. di Medicina Interna, Ospedale del Delta, Azienda U.S.L. di Ferrara, Ferrara, Italy e-mail: r.manfredini@ausl.fe.it