Community acquired pneumonia in internal medicine: a one-year retrospective study based on pneumonia severity index.

Community acquired pneumonia (CAP) represents the sixth cause of death and the first cause of death for an infectious disease in the USA. The aim of the present study is to evaluate how CAP is managed in a hospital setting, with particular attention to the wards of internal medicine, compared to the recommendations based and validated PSI (Pneumonia Severity Index). 42 subjects were included in the study, 25 males and 17 females. According to the PSI, nine (21%) patients were classified in class I, two (5%) in class II, ten (24%) in class III, fifteen (36%) in class IV and six (14%) in class V. Three patients died during the stay in the hospital (2 males and 1 female), all in the highest PSI class (V). According to the criteria used to evaluate the adequacy of the admission to the hospital, twentyeight patients were classified in the HRG, with an appropriate admission, whilst fourteen (33%) were in the LRG, with an inappropriate admission to the hospital. The data of the study confirm the validity of a PSI based strategy for the management of CAP since admittance to the hospital. This approach is not yet widely implemented in Italy, and a better dialogue between hospital and health system representatives would be convenient, to reduce costs and ensure the safety of patients affected by CAP.

Sarcopenia is more than a muscular deficit.

Sarcopenia is a complex process that appears in aged muscle associated with a decrease in mass, strength, and velocity of contraction. This process is the result of many molecular, cellular and functional alterations. It has been suggested that sarcopenia may be triggered by reactive oxygen species (ROS) that have accumulated throughout one's lifetime. We found a significant increase in oxidation of DNA and lipids in the elderly muscle, more evident in males, and a reduction in catalase and glutathione transferase activities. Experiments on Ca2+ transport showed an abnormal functional response of aged muscle after exposure to caffeine, which increases the opening of Ca2+ channels, as well a reduced activity of the Ca2+ pump in elderly males. From these results we concluded that oxidative stress play an important role in muscle aging and that oxidative damage is much more evident in elderly males, suggesting a gender difference may be related to hormonal factors. The progression of sarcopenia is directly related to a significant reduction of the regenerative potential of muscle normally due to a type of adult stem cells, known as satellite cells, which lie outside the sarcolemma and remain quiescent until external stimuli trigger as growth factors (IGF-1 or mIGF-1) their re-entry into the cell cycle. One possibility is that the anti oxidative capacity of satellite cells could also be altered and this, in turn, determines the decrease of their regenerative capacity. Data concerning this hypothesis are discussed

The 'real' woman with heart failure. Impact of sex on current in-hospital management of heart failure by cardiologists and internists.

AIM: To identify differences between sexes in the clinical profile, use of resources, management and outcome in a large population of 'real world' patients with heart failure (HF). METHODS: A prospective cross-sectional survey was conducted on 2127 consecutive patients (47% women) admitted with HF to 167 cardiology and 250 internal medicine departments between February 14 and 25, 2000. RESULTS: Women were older, had a higher prevalence of atrial fibrillation, and more frequently a hypertensive or valvular aetiology. Females were admitted more frequently in Medical than in Cardiology Departments. The rate of invasive and non-invasive procedures was lower in women than in men, slightly higher if managed by cardiologists. Women were less frequently prescribed ACE-inhibitors, amiodarone, and spironolactone, and more frequently prescribed digoxin. In-hospital mortality was similar, without difference between health-care providers. A 6-month follow-up was performed in 56.4% of the cases in both setting, but less frequently in women. Event rates were similar with nearly half of patients re-hospitalised at least once. CONCLUSION: The 'real' HF woman has generally a more severe disease; she is an old lady who is more frequently hospitalised in a medical unit, receives few diagnostic, and cardiovascular procedures and pharmacological therapy, has a relatively low probability of dying in hospital, but a high likelihood of requiring readmission.

[Chlamydia pneumoniae and Helicobacter pylori infections in acute myocardial infarction]. / Infezione da Chlamydia pneumoniae e da Helicobacter pylori nell'infarto miocardico acuto.

BACKGROUND: Increasing evidence suggests an acute or chronic linkage between infection and acute coronary syndromes. The aim of this study was to assess the frequency of Chlamydia pneumoniae (CP) and Helicobacter pylori (HP) antibodies in patients with angiographically defined acute myocardial infarction and in population controls. Case patients and controls were drawn from the same geographic area (city of Messina and its province). METHODS: Blood samples were collected in 206 incident cases of acute myocardial infarction presenting to the Coronary Care Unit (196 men, 10 women, mean age 58+/-7 years) in the period from March 1997 to June 1999. Case patients were selected if they were non-smokers, non-diabetic and if they had no history of hypertension. The control group consisted of 142 healthy subjects, without a known history of smoking, diabetes, and hypertension. Controls were matched to acute myocardial infarction patients for age, sex and socio-economic status. Commercial ELISA assay was used to measure IgG antibody to HP (positive titer > 8 IU/ml) and indirect immunofluorescence method was used to assess IgG antibody anti-CP (IgG titer > 1:64 was considered a marker of chronic infection). RESULTS: No significant difference was observed in the frequency of HP antibodies in acute myocardial infarction patients and in the control group (43.3 vs 41.5%, p = NS, odds ratio-OR 1, 95% confidence interval-CI 0.7-1.6). On the contrary, CP titers were increased in 83% of acute myocardial infarction patients, and in 57% of control subjects (p < 0.001, OR 3.6, 95% CI 2.2-5.7). In acute myocardial infarction patients seropositivity for CP was associated with increased basal fibrinogen levels (539 vs 445 mg/dl). No correlation was found between seropositivity to CP and C-reactive protein, and with total or fractionated cholesterol and triglyceride concentrations. CONCLUSIONS: The present data indicate that, in our sample, acute myocardial infarction was associated with an increased frequency of CP seropositivity. The presence of CP antibodies was not associated with elevated levels of C-reactive protein. Our data support the need for controlled studies to investigate the role of these infective agents as a trigger of acute coronary syndromes.

Ultrastructural changes in rat cornea after prolonged hypobaric hypoxia.

A study was performed to evaluate the effect of prolonged environmental hypobaric hypoxia on the ultrastructure of rat cornea. 60-day-old female Wistar rats were exposed to a simulated altitude of 5,500 m (350 mmHg) and pO2 of 76 mmHg for 30 days. Control rats were exposed to atmospheric sea level pressure (760 mmHg) and pO2 of 150 mmHg, for the same period. Ultrastructural analysis of the corneal epithelium did not reveal any relevant difference between control and treated rats. In contrast, the corneal stroma of rats subjected to hypoxia showed vascularization with advanced vessel differentiation and signs of active proliferation. The endothelium of hypoxic cornea showed swollen mitochondria and large empty cytoplasmic areas. The endothelial intercellular junctions could hardly be identified in the hypoxic condition. Nevertheless, the most evident change in hypoxic cornea was in Descemet's membrane, which was considerably thickened, to approximately twice that of the control specimen. These results suggest that environmental hypobaric hypoxia induces marked alterations in the corneal stroma and endothelium morphology, probably related to reduced oxygen tension in the aqueous humor, consequent to hypoxemia.

Thrombolytic therapy with urokinase reduces increased circulating endothelial adhesion molecules in acute myocardial infarction.

The aim was to investigate circulating E-selectin and Intercellular Adhesion Molecule-1 (ICAM-1) in acute myocardial infarction. Our study was carried out in 80 patients, 40 hospitalized for acute myocardial infarction (AMI), 20 suffering from chronic stable angina and 20 healthy control subjects. Samples of venous blood were taken from all patients at the moment of hospitalization and after 2, 4, 6, 8, 10, 12 and 24 hours from the thrombolytic treatment (AMI + urokinase) or conventional therapy (AMI + nitroglycerin), for the dosage of creatinine kinase (CK) and adhesion molecules. The CK was determined by means of a Hitachi 901 automatic analyser using an enzymatic method (reagents Boheringer-Biochemia, Germany). Soluble E-selectin (sE-selectin) and soluble ICAM-1 (sICAM-1) were measured in the serum using a specific immunoassay (British Biotechnology Products). The serum levels of Tumor Necrosis Factor (TNF-alpha) were evaluated using an immunoenzymatic assay to quantitate the serum levels of the cytokine (British Biotechnology Products). Patients with acute myocardial infarction (AMI) had increased serum levels of soluble E-selectin (sE-selectin; AMI + urokinase = 312 +/- 20 ng/ml; AMI + nitroglycerin = 334 +/- 15 ng/ml) and soluble ICAM-1 (sICAM-1; AMI + urokinase = 629 +/- 30 ng/ml; AMI + nitroglycerin = 655 +/- 25 ng/ml) compared to both patients with chronic angina (sE-selectin = 67 +/- 10 ng/ml; sICAM-1 = 230 +/- 20 ng/ml) and healthy control subjects (sE-selectin = 53 +/- 15 ng/ml; sICAM-1 200 +/- 16 ng/ml). Furthermore patients with acute myocardial infarction also had increased serum levels of Tumor Necrosis Factor (TNF-alpha = 309 +/- 10 pg/ml; control subjects = 13 +/- 5 pg/ml). Thrombolytic therapy with urokinase (1,000,000 IU as an intravenous bolus for 5 minutes, followed by an infusion of an additional 1,000,000 IU for the following two hours) succeeded in producing reperfusion and reduced the serum levels of sE-selectin (52 +/- 13 ng/ml) and sICAM-1 (202 +/- 31 ng/ml). In contrast patients not eligible for thrombolytic therapy and therefore treated with conventional therapy (a continuous i.v. infusion of nitroglycerin at the dose of 50 mg/die) did not show any significant reduction in both sE-selectin and sICAM-1 throughout the study. Our results confirm previous experimental data and indicate that adhesion mechanisms supporting leukocyte-endothelium interaction may also be operative in human acute myocardial infarction.

Early reactivation of ischaemia after abrupt discontinuation of heparin in acute myocardial infarction.

Intravenous heparin after thrombolytic therapy for acute myocardial infarction is an effective, widely used treatment. Six cases of acute myocardial infarction are reported with early disease reactivation following the abrupt discontinuation of heparin infusion three days after alteplase thrombolysis and concomitant aspirin therapy. Immediate reinfusion of heparin resulted in regression of symptomatic ischaemia in all six patients. The activated partial thromboplastin time values, determined four hours before the discontinuation of heparin therapy, were within the therapeutic range in five of the six patients, and no difference was found in the values obtained one hour after the reinfusion of heparin (P = 0.065).

Myocardial bridging involving more than one site of the left anterior descending coronary artery: an uncommon cause of acute ischemic syndrome.

An infrequent angiographic finding is reported of myocardial bridging involving more than one site of the left anterior descending coronary artery in a symptomatic patient with ischemia exacerbated by nitroglycerin administration. Beta-blocker therapy alone was followed by a favorable long-term outcome.

[Aortic stenosis and coronary pathology. Their implications for the transvalvular gradient]. / Stenosi aortica e coronaropatia. Implicazioni sul gradiente transvalvolare.

To assess the incidence of coronary artery disease in patients with valvular aortic stenosis and its implication on peak systolic valvular gradient, 31 consecutive patients who underwent cardiac catheterization were examined. Associated significant coronary artery disease (> 50% reduction in luminal diameter evaluated in proximal segments and right dominant circulation) was present in 54.8% of patients. There was no difference in the distribution of risk factors among patients with and without significant luminal narrowings. The prevalence of coronary artery disease was found not to be significantly correlated with age (p = 0.276). There was no relationship between typical angina pectoris and the presence of coronary artery disease (p = 0.063). Fourty-seven percent of cases resulted free of chest pain. Ejection fraction was found to be significantly lower in patients with coronary artery disease (45 +/- 14.2%) than in patients without coronary artery disease (65.1 +/- 3.9%; p = 0.03) and a reverse relationship was observed between the presence of coronary artery disease and peak systolic valvular gradient (p = 0.006) which, in turn, correlated significantly with ejection fraction (r = 0.68; p = 0.023). These data demonstrate that the value of peak systolic valvular gradient, as the only index for the evaluation of the severity of aortic stenosis, is greatly limited in patients with associated coronary artery disease. Moreover, confirming the guidelines of the American College of Cardiology and of the American Heart Association task force, these data also stress the necessity of performing coronary angiography regardless angina pectoris is present or not.

[Unusual anatomic coronary variants: parallel left anterior descending artery. Description of 3 cases]. / Insolita variante anatomica coronarica: ramo discendente anteriore parallelo. Descrizione di 3 casi.

Three cases with a variation of the classic anatomic left anterior descending artery pattern, encountered unexpectedly during coronary arteriography, are reported. The importance of this unusual and rare coronary artery pattern is only anatomic, and the possibility to carry out these findings by the coronary arteriography, can increase their occurrence instead of an incidental finding.

Change in plasma amino acid concentrations during breath-hold diving at high altitude.

We studied the plasma concentration of various amino acids in 6 Italian sport divers in Italy and at approximately 4,500 m altitude in Peru; 6 Peruvian inhabitants were examined for comparison. We attempted to create a situation of pronounced hypoxia in muscles by breath-hold diving at altitude. The diving reflex diverts blood away from muscles while diving increases central oxygen tension and prevents loss of consciousness. Differences in certain amino acids, probably related to diet, were noted between Italy and Peru. Increases in concentration of plasma alanine and some branched-chain amino acids occurred after breath-hold diving. These changes were similar to those seen after prolonged hard exercise, even though physical work was low. Hypoxia in muscles, common during hard work and during breath-hold diving at altitude, might thus be the stimulus for amino acid release from working muscles.