Shoulder periprosthetic fracture in elderly patient: a minimally invasive osteosynthesis and "off-label" treatment with teriparatide. A case report and literature review.

A case of shoulder periprosthetic fracture in elderly patient. The patient underwent a minimally invasive osteosynthesis and "off-label" treatment with teriparatide. An 80-year-old woman patient following an accidental fall reported a transverse displaced diaphyseal fracture of the right humerus, distal to the stem of the inverse prosthesis. The patient suffering from severe osteoporosis and chronic ischaemic heart disease. The patient underwent fracture osteosynthesis surgery using a Hoffmann III mono-axial external fixator. Teriparatide administered at a dosage of 20 micrograms/day, for four months. At six months from the beginning of th e hybrid treatment, a complete healing of the fracture was observed radiologically and clinically. It is possible to affirm that the use of teriparatide off-label has a positive and additive effect in promoting the healing of fractures.

[Italian consensus on the recommendations about the use of methotrexate for the treatment of rheumatic diseases with a focus on rheumatoid arthritis: results from the "3E initiative"]. / Consensus italiana sulle raccomandazioni per l'utilizzo del methotrexate nelle malattie reumatiche con focus sull'artrite reumatoide: i risultati della "3E initiative".

OBJECTIVE: To develop a set of national evidence-based recommendations for the use of Methotrexate (MTX) in daily clinical practice. METHODS: A panel of 37 Italian Rheumatologists reviewed 10 international recommendations formulated during the "3E (Evidence, Expertise, Exchange) initiative" for the year 2007-8, following a systematic literature search in Medline, Embase, Cochrane Library, and 2005-7 American College of Rheumatology/European League Against Rheumatism meeting abstracts and the revision of selected papers and the appraisal of Oxford levels of evidence. Moreover, the same panel by the same methodology formulated further 5 recommendations on topics previously selected by Italian representatives to 3E initiative. The agreement about the set of proposed recommendations was stated by a consensus process and the potential impact on clinical practice was assessed. RESULTS: International Recommendations were analysed and changed when appropriate. In addition, 5 national recommendations were developed by identifying 6371 references, selecting and evaluating the 29 ones satisfying Evidence Based Medicine principles. CONCLUSIONS: A set of 15 national recommendations for the use of MTX in daily clinical practice was developed. These recommendations are evidence-based and integrate the expertise of a large panel of Italian rheumatologists.

The relationship between terazosin dose and blood pressure response in hypertensive patients.

A double-blind, randomized, placebo-controlled, multicenter study was conducted to describe the dose-response curve for terazosin on blood pressure. A total of 128 patients with mild to moderate essential hypertension (supine diastolic blood pressure, 100 to 114 mmHg) participated in the study. The study consisted of a 4-week single-blind placebo lead-in period and a 14-week double-blind treatment period. Patients were randomized in equal numbers to four parallel treatment groups: terazosin 1, 2, and 5 mg; terazosin 2, 5, and 10 mg; terazosin 20, 40, and 80 mg; and placebo. The 24-hour ambulatory blood pressure measurements were performed at the end of the placebo lead-in period and at the end of each 4-week fixed-dose period. The nonlinear, mixed-effect model computer program was used to analyze the dose-response relationship. There was a strong dose-response relationship between fall in blood pressure and the 1 to 10 mg terazosin dose, as well as a plateauing of response for terazosin doses above 10 mg. The maximum antihypertensive response (Emax) to terazosin was 10.7 mmHg for systolic blood pressure and 8.0 mmHg for diastolic blood pressure. The daily dose of terazosin, which produced 50% of the maximum response (ED50), was 3.0 mg for systolic blood pressure and 1.5 mg for diastolic blood pressure. The results of this study suggest that although some patients may benefit from terazosin doses of greater than 10 mg, doses up to 10 mg will maximize therapeutic benefit for most patients, with acceptable side effects.

[Polydistrectual atherosclerosis in the elderly. Ischemic cardiopathy and obliterative peripheral arteriopathy of the lower limbs]. / Aterosclerosi polidistrettuale nell'anziano. Cardiopatia ischemica e arteriopatie obliteranti periferiche degli arti inferiori.

BACKGROUND: Numerous epidemiological studies have recently drawn attention to the polydistrict nature of atherosclerotic disease. In particular, it has been made clear the frequent association between coronary heart disease and peripheral arterial disease of the lower limbs. We have therefore evaluated the frequency of peripheral arterial disease in a consecutive unselected series of patients affected by coronary heart disease, over 65 and under 65. We have besides evaluated the frequency of some factors of risk for atherosclerotic disease on the subjects affected by coronary heart disease alone and in those with associated peripheral arterial disease. METHODS: We have studied 502 patients (280 males and 222 females) with coronary heart disease admitted to the II Division of General Medicine of Pugliese-Ciaccio Hospital of Catanzaro. Of the 502 patients examined, 367 (72.7%) over 65 and 137 (27.3%) under 65. Factors of risk considered were familiarity, cigarette smoking, diabetes mellitus, dyslipidosis, arterial hypertension. RESULTS AND CONCLUSIONS: Peripheral arterial disease was present in 37% of the subjects examined. In the elderly group there was a frequency of 87.6%, while in subjects under 65 the frequency was 12.4%. Symptoms of claudicatio were present in 100% of the subjects under 65 and 58.6% of the elderly subjects. Risk factors that apply with greater frequency were diabetes mellitus, arterial hypertension and smoking. The results of our study show the importance of searching for stenosis even if asymptomatic in patients with coronary heart disease, above all if elderly.

[Nailfold capillaroscopy in the study of microcirculation in childhood]. / La capillaroscopia periungueale nello studio del microcircolo in età pediatrica.

The nailfold capillaroscopy allows to study the microcirculation: for its simple and rapid execution it can be used also in children. We examined the nailfold capillaroscopy features in childhood and valued the maturation of microcirculation in connection to age and presented some pathologic patterns. We studied nailfold capillaroscopy patterns in sixty-six children without chronic cutaneous diseases. Our results showed that development of microcirculation during childhood is incomplete. In connection to age we observed the capillaries are arranged as arches in children younger than six months, there are disposed as saddles between 12 and 24 months and they became similar to those of the adult at about 10-11 years. We observed immature capillaries in one child with hypothyroidism and one's delay growth. The cutaneous hemorrhages were rarely found in children who bit the in nails. The capillaroscopy is helpful to value the maturation of the capillaries from the birth to the adolescence. Moreover we would like to underline how our children took part to this exam almost like as if it were a game.

Nail-fold capillaroscopy in the study of microcirculation in elderly hypertensive patients.

Hypertension represents one of the most important atherosclerotic risk factors, since it causes vascular damage both to macro- and microcirculation. Capillaroscopy is very useful to examine "in vivo" the small vessels of nail-fold and conjunctival layer of the bulb which are the most suitable areas for a morphological study of microcirculation. Capillaroscopy gives remarkable information from a clinical and diagnostic point of view, both in the diseases involving microcirculation (connective tissue disorders, diabetes) and in the evaluation of microvascular impairments in systemic diseases such as arterial hypertension. Aim of the present study was at evaluating capillaroscopic characteristics in a consecutive and non-selected series of elderly hypertensive patients and comparing the results to those observed on fundus oculi. Our study revealed the decrease of the number of capillary loops which appear thin and lengthened, in the hypertensive persons, as compared to the control group. Dilated and tortuous capillaries, arteriovenous sludge and "flea bite" juxtacapillary microhemorrhages were found more frequently in the patients with isolated systolic hypertension; they are linked to the atherosclerotic nature of that disease.

[Abdominal aortic aneurysm in the elderly]. / L'aneurisma dell'aorta addominale nell'anziano.

AIM: Complication-free abdominal aortic aneurysm is often asymptomatic and its diagnosis is therefore frequently coincidental. Abdominal aortic aneurysm (AAA) is often suddenly manifested during the rupture stage, resulting in the patient's death. The importance of early diagnosis is therefore clear, enabling optimal monitoring and correct management. EXPERIMENTAL DESIGN AND SUBJECTS: This retrospective study evaluated the incidence of AAA in 1304 over-65-year-olds in care. The authors examined the presence of AAA-related symptoms, risk factors and the concomitance of other pathologies. RESULTS: Four subjects were diagnosed with AAA, equivalent to 0.3% of the total population. All were male, smokers, with multidistrict atherosclerosis in association with other pathologies. CONCLUSIONS: The incidence of AAA in the population of over-65-year-olds examined was lower than that reported in the literature. This discrepancy was due to the fact that the abdominal aorta is not usually examined in clinical practice. However, the high mortality rate of AAA during rupture prompted the authors to evaluate this disorder in high-risk patients.