Effect of pilocarpine mouthwash on salivary flow

Pilocarpine is a cholinergic agonist that increases salivary flow and has been used to treat xerostomia. Oral intake is the most frequent route of administration. Adverse effects are dose-dependent and include sudoresis, facial blushing and increased urinary frequency. The objective of the present study was to evaluate the effects of topical pilocarpine solutions as mouthwashes on salivary flow and their adverse effects on healthy subjects. Forty volunteers received 10 ml 0.5, 1 and 2 percent pilocarpine solutions or 0.9 percent saline in a randomized, double-blind, placebo-controlled manner. Salivation was measured before and 45, 60 and 75 min after mouth rinsing for 1 min with 10 ml of saline or pilocarpine solutions. Vital signs were measured and ocular, gastrointestinal and cardiovascular symptoms, anxiety and flushing were estimated using visual analog scales. There was a dose-dependent increase in salivation. Salivation measured after 1 and 2 percent pilocarpine (1.4 +/- 0.36 and 2.22 +/- 0.42 g, respectively) was significantly (P<0.001) higher than before (0.70 +/- 0.15 and 0.64 +/- 0.1 g), with a plateau between 45 and 75 min. Cardiovascular, visual, gastrointestinal and behavioral symptoms and signs were not changed by topical pilocarpine. Mouth rinsing with pilocarpine solutions at concentrations of 1 to 2 percent induced a significant objective and subjective dose-dependent increase in salivary flow, similar to the results reported by others studying the effect of oral 5 mg pilocarpine. The present study revealed the efficacy of pilocarpine mouthwash solutions in increasing salivary flow in healthy volunteers, with no adverse effects. Additional studies on patients with xerostomia are needed

Effect of pilocarpine mouthwash on salivary flow.

Pilocarpine is a cholinergic agonist that increases salivary flow and has been used to treat xerostomia. Oral intake is the most frequent route of administration. Adverse effects are dose-dependent and include sudoresis, facial blushing and increased urinary frequency. The objective of the present study was to evaluate the effects of topical pilocarpine solutions as mouthwashes on salivary flow and their adverse effects on healthy subjects. Forty volunteers received 10 ml 0.5, 1 and 2% pilocarpine solutions or 0.9% saline in a randomized, double-blind, placebo-controlled manner. Salivation was measured before and 45, 60 and 75 min after mouth rinsing for 1 min with 10 ml of saline or pilocarpine solutions. Vital signs were measured and ocular, gastrointestinal and cardiovascular symptoms, anxiety and flushing were estimated using visual analog scales. There was a dose-dependent increase in salivation. Salivation measured after 1 and 2% pilocarpine (1.4 +/- 0.36 and 2.22 +/- 0.42 g, respectively) was significantly (P<0.001) higher than before (0.70 +/- 0.15 and 0.64 +/- 0.1 g), with a plateau between 45 and 75 min. Cardiovascular, visual, gastrointestinal and behavioral symptoms and signs were not changed by topical pilocarpine. Mouth rinsing with pilocarpine solutions at concentrations of 1 to 2% induced a significant objective and subjective dose-dependent increase in salivary flow, similar to the results reported by others studying the effect of oral 5 mg pilocarpine. The present study revealed the efficacy of pilocarpine mouthwash solutions in increasing salivary flow in healthy volunteers, with no adverse effects. Additional studies on patients with xerostomia are needed.

[Cardiac injury in acute cerebral vasculopathy]. / Sofferenza cardiaca in corso di vasculopatia cerebrale acuta.

Cardiac complications, including focal myocytolysis, electrocardiographic changes, arrhythmias and left ventricular wall motion abnormalities, frequently occur following stroke and contribute to worsen the prognosis. Their clinical spectrum seems to be related to the type of cerebrovascular disease and its localization. Thus, the incidence of arrhythmias and pulmonary edema is significantly higher in subarachnoid hemorrhage than in ischemic stroke, and the lesions in the right insular cortex are a major risk for complex arrhythmias and sudden death. Elevated plasma norepinephrine levels are frequently associated with these events and strongly suggest an underlying sympathetically mediated mechanism. The autonomic and cardiovascular effects of stroke, however, are modulated by concomitant factors such as pre-existent cardiac diseases, electrolyte disorders and, probably, by genetic alterations in the ionic control of myocyte repolarization. Although beta-blockers have been reported to prevent myocardial damage following stroke, adequate clinical trials are lacking, and the widespread use of these drugs in acute cerebrovascular disease is not supported by evidence.

C-reactive protein on admission as a predictor of in-hospital death in the elderly with acute myocardial infarction.

BACKGROUND: The mean age of patients with acute myocardial infarction is increasing and the associated in-hospital mortality is exponentially age-related. Inflammation markers have been related to cardiovascular short and long-term prognosis. The aim of this study was to evaluate the short-term prognostic value of C-reactive protein (CRP) levels on admission in the oldest segment of the patients with acute myocardial infarction. METHODS: CRP was prospectively measured on admission by immunonephelometry in 205 consecutive old women (mean age 82 +/- 5 years) with definite acute myocardial infarction; values were then related to in-hospital mortality and the causes of death. RESULTS: CRP levels ranged from 0.1 to 31.9 mg/dl and were raised in 71% of the patients. It showed no significant correlation with baseline clinical variables such as age, history of diabetes or hypertension or prior myocardial infarction, infarct location, and time from symptom onset to admission. The overall in-hospital mortality rate was 25% and rose from 15% among patients in the lower three quartiles of CRP levels (cut point 6.4 mg/dl) to 55% among those in the upper quartile (p < 0.001). By univariate logistic-regression, the odds ratio for early death was 0.84 (95% confidence interval 0.78-0.89) for every increase by 1 mg/dl of CRP, and 5.7 (95% confidence interval 2.7-11.9) for a CRP level in the upper quartile. Multivariate analysis demonstrated the independence of the relation between CRP levels and in-hospital mortality (p = 0.0001). No significant differences in CRP level were found among deceased patients classified by cause of death (heart rupture 44%, pump failure 41%, comorbidity 5%). CONCLUSIONS: CRP concentration is raised in many old patients with acute myocardial infarction and seems to independently stratify patients for in-hospital mortality risk. This prognostic information may assist in providing the appropriate level and duration of close monitoring and be an additional support to evaluate the risk-benefit ratio of thrombolytic therapy in some cases.

Threshold energy dose for enzyme release after direct-current countershock.

Serial measurement of serum total creatine kinase and creatine kinase MB isoenzyme was prospectively performed by photometric assay in 82 consecutive patients (55 male and 27 female; mean age 62 +/- 11 years) after elective DC countershock for atrial flutter or fibrillation. Enzyme release is commonly observed to follow DC shock; the related energy threshold for enzyme release, however, a parameter with potential clinical usefulness, has not yet been determined. The energy dose was individually titrated but the anterolateral paddle-electrode location was used in all cases. The mean +/- S.D. (range) of shock number, peak energy level and cumulative energy dose normalized to body weight were respectively: 1.7 +/- 0.9 (1-5), 228.6 +/- 87.6 (75-400) J and 5.26 +/- 3.74 (1.0-19.7) J/kg. All these parameters had highly significant positive correlation with enzyme release (P < 0.0001), which peaked 16 h after countershock. Only creatine kinase levels changed significantly vs. baseline (P < 0.0001). As evidenced by dose vs. effect scattergram, the energy threshold value for enzyme release was around 4 J/kg for creatine kinase and 6 J/kg for creatine kinase MB isoenzyme. These energy dose figures may provide clinical usefulness to avoid unnecessary muscle damage; moreover, they may be used as a reference when enzyme elevations interfere with the diagnosis of a concomitant ischemic acute myocardial infarction.

Prognostic value of Holter monitoring in asymptomatic elderly subjects with sinus rhythm.

Elderly people, even if asymptomatic and in apparently good cardiovascular condition, have a high incidence of cardiovascular events. Prognostic markers by noninvasive procedures would therefore be desirable. The aim of this study was to evaluate the prognostic usefulness of Holter monitoring in this setting. Holter findings in 50 asymptomatic elderly subjects with sinus rhythm were correlated with major clinical cardiovascular events occurring during a 5-year follow-up period (16% incidence). No significant association was found with any baseline arrhythmia category, even complex arrhythmias such as unsustained ventricular tachycardia, which had a 10% baseline prevalence. On the other hand, cardiovascular events were correlated (P < .01) with the presence of silent ST-segment depression (8% baseline prevalence), which seems to have an unfavorable clinical significance, in elderly, as well as younger, people. Holter monitoring, because of the benignity of high-prevalence findings and the very low incidence of unfavorable events, has an overall limited prognostic usefulness in asymptomatic elderly subjects with sinus rhythm. In a cost-conscious medical environment, its use seems to be justified only in selected cases.

[Recent morphofunctional findings on the left atrium: their relations to thromboembolic risk]. / Recenti acquisizioni morfo-funzionali sull'auricola sinistra: rapporti con il rischio tromboembolico.

In the past, the left atrial appendage has been considered a "useless" structure but associated to thromboembolic complications; its physiologic role is still undefined. Owing to its great distensibility, left atrial appendage positively influences atrial compliance and left ventricular performances. In addition this structure seems to play an important role in circulatory homeostasis by the release of atrial natriuretic factor in response to volume loading and atrial stretch. Transesophageal echocardiography provides a detailed anatomical characterization of this structure and, by means of Doppler flow velocities recordings, supplies relevant functional data. Despite their anatomical contiguity, the left atrium and atrial appendage result from a separate embryonic development; likewise, their function may differentiate. In the left atrial appendage a quadriphasic flow pattern has been described in subjects with sinus rhythm; however, as we reported, in some patients a more complex Doppler pattern can be observed, with an additional systolic forward flow wave which is presumably due to reflection phenomena. In patients with atrial fibrillation, an irregular flow pattern has been detected, which is mostly dependent on the duration of the arrhythmia, the underlying heart disease and the left atrial pressure. By transesophageal echocardiography a clear correlation has been established between the left atrial appendage slow flow and the occurrence of thromboembolic events; however, while waiting data from large studies, stratification of patients according to thromboembolic risk and decisions about anticoagulant prophylaxis should be performed by clinical information and transthoracic echocardiographic findings. No clinical or echocardiographic parameter has been found to be predictive of the thromboembolic events after cardioversion; in this setting the exclusion of atrial or atrial appendage thrombi by transesophageal echocardiography does not rule out the need for anticoagulation in patients with atrial fibrillation undergoing electrical or pharmacological cardioversion.

Double orifice in prolapsing mitral valve.

A prolapsing mitral valve with a double orifice ('hole type') was documented by echocardiography in a 35-year-old male. His symptoms were associated to supraventricular ectopic beats and persisted unchanged during a 3-year follow-up. This malformation is usually considered benign but, as fragmentation of the atrioventricular conduction tissue was reported in some cases, a periodic observation is advisable.

[Spontaneous (idiopathic) pneumopericardium. A case report and review of the literature]. / Pneumopericardio spontaneo (idiopatico). Descrizione di un caso e revisione della letteratura.

Pneumopericardium is a rare entity, but it can occur in a wide variety of clinical situations. The spontaneous cases are very rare and generally can be associated with some predisposing or precipitating conditions. We report a case in which the pathogenesis of pneumopericardium undefined after conventional diagnostic clinical investigation. A concise review of the recent literature is presented, and some practical clinical remarks are made.

[Systemic arterial hypertension in chronic alcoholics. Role of the abstinence syndrome]. / L'ipertensione arteriosa sistemica negli alcoolisti cronici. Ruolo della sindrome astinenziale.

A significantly positive association (p less than 0.001) has been shown between so called "minor" ethanol withdrawal-syndrome and raised systolic and diastolic blood pressure values in 328 hospitalized chronic alcoholics. In a subgroup of patients with clinical and histological findings of alcoholic hepatic cirrhosis, this association was absent (p greater than 0.5). In chronic alcoholics with several hospital admissions, a nearly constant relationship of "minor" ethanol withdrawal-syndrome to systolic and diastolic hypertension has been shown. Mild or early abstinence states in alcoholics - which may pass off undetected or misinterpreted in outpatient clinic examination - are possibly responsible for the positive association between hypertension and alcoholism reported by others in several epidemiologic studies. Therefore, high blood pressure values in a chronic alcoholic patient - even if detected on several occasions - need special clinical considerations and we think they do not mean alcohol-induced hypertension. From another point of view, high blood pressure values may give a hint for detection of hidden alcoholism.

[Biochemical indicators in chronic alcoholism. Comparison between the enzymes glutamate dehydrogenase and gamma glutamyl transferase]. / Indicatori biochimici nell'alcoolismo cronico. Confronto fra gli enzimi glutamico-deidrogenasi e gamma-glutamil-transferasi.

Serum concentrations of glutamate dehydrogenase (GDH) and gamma-glutamyl-transpeptidase (GGT) have been determined in 93 chronic alcoholics regularly taking at least 150 g of alcohol daily, and in 35 healthy teetotal subjects. Both these enzymes were increased in the alcoholic group (P less than 0.001). The incidence of "false negatives" (alcoholics with normal enzymes) may be considered equal (25 and 29% respectively) while "false positives" (teetotal subjects with increased enzymes) were less frequent for glutamate-dehydrogenase (17 against 37%). In 20% of alcoholics one enzyme was normal while the other was increased; the serum increase of these two enzymes probably indicates different hepatic lesions. The search for a reliable biochemical marker of hepatocyte necrosis cannot be considered concluded; hystologic examination is still necessary to assess alcohol-related hepatic necrosis. Our study has shown that glutamate-dehydrogenase has an equal sensibility to gamma-glutamyltranspeptidase but a higher specificity as an indicator of alcohol abuse.

[Radiologic projection on the sagittal plane as a diagnostic parameter in primary lung neoplasms]. / La proiezione radiologica sul piano sagittale come parametro diagnostico nelle neoplasie primitive del polmone.

A study was carried out to evaluate the importance of location of radiological densities on lateral protection of X-ray films of the chest, as a valuable sign for the clinical diagnosis of primary neoplasms of the lung. Clinical case records of 100 patients with pneumonitis, 61 patients with active pulmonary tuberculosis and 58 cases with primary pulmonary neoplasms -- in which diagnosis was verified by hystological examination of biopsies performed during bronchoscopy or by autoptic control -- were reviewed. Radiological location in anterior or central-anterior planes was observed in only 14 per cent of patients with pneumonitis while in 86 per cent the location was in posterior or central-posterior planes. Only 10 per cent of patients with active pulmonary tuberculosis had their densities situated on anterior or central-anterior planes of the chest X-ray while in the remaining 90 per cent of cases the location was in central-posterior or posterior planes of the radiogram. In 74 per cent of patients with primary lung neoplasms we observed that radiological densities were located in the anterior or central-anterior planes; only in 26 per cent of patients the radiological location was in the posterior or central-posterior planes. Since in most instances of primary lung neoplasms the initial diagnostic approach is roentgenographic, it seems of particular importance in differential diagnosis to consider as neoplastic those lesions located in the anterior planes of an X-ray film taken in lateral projection until proven otherwise. This radiological aspect implies the opportunity to perform a bronchoscopic and hystological evaluation even in those patients in which clinical aspects should seem less suggestive of primary lung neoplasm. A posterior location does not exclude -- according to our data -- the neoplastic origin of a density but this radiological criterion does seem to justify a less aggressive diagnostic approach in all those patients which present contraindications or refuse invasive procedures.

[Macrocytosis and anemia in chronic alcoholism. Correlation with the results of hepatic needle biopsy]. / Macrocitosi ed anemia nell'alcoolismo cronico. Correlazione con i reperti dell'agobiopsia epatica.

Clinical and laboratory observations were made on 220 chronic alcoholics, regularly taking at least 150 g of alcohol daily. Haematological data concerning white blood cells, platelets and red cells counts, mean corpuscolar volume, hemoglobin and serum iron in these patients were compared with control values obtained from 150 healthy teetotal subjects. Hematological changes in chronic alcoholics were correlated with histological liver damages in transcutaneous needle-biopsies. No statistical differences were evident for white cells and platelets counts and for serum iron content; however, in chronic alcoholics, serum iron content showed a great dispersion around the mean. Mean corpuscolar volume (MCV) was significantly increased (P less than 0,001) in chronic alcoholics (even in those with a normal liver biopsy) but there was no significant difference in the degree and the incidence of macrocytosis between patients showing normal liver appearances or fatty changes only, and those showing more severe damage, i.e, acute alcoholic hepatitis (with or without steatosis), central hyaline-sclerosing necrosis and or hepatofibrosis, cirrhosis and hepatocarcinoma. No significant difference was seen between male and female alcoholics. Macrocytosis may be considered as an early marker for alcoholism but it does not correlate with the type of histological liver damage. Hemoglobin levels were significantly reduced in chronic alcoholics (P less than 0,01): the degree and incidence of anemia were more severe in those patients with advanced liver diseases and in female alcoholics. There is no statistically significant correlation between macrocytosis and anemia.

[Current status and problems of tuberculosis. 10 years of experience in a general medicine department]. / Aspetti e problemi attuali della tubercolosi. Esperienza di 10 anni in un reparto di medicina generale.

One hundred and seventeen cases of tuberculous disease who came to the Authors' observation in 10 years are described. Some cases are illustrated in details just to point out the complexity and the different guises of clinical presentation and to underscore the importance of an high index of suspicion for tuberculosis in patients who are admitted to a ward of internal medicine. In 71 patients with active, progressive tuberculous disease, the diagnosis was confirmed by bacteriological findings in 29 cases and by bioptical and hystological data in 5 cases; in the remaining 37 cases only clinical and radiological criteria were met but the diagnosis was confirmed by the improvement which was observed after antimycobacterial therapy. Many difficulties have been met in the differential diagnosis between pulmonary tuberculosis and bronchogenic carcinoma in those cases with anamnestic and radiological data of previous pulmonary tuberculosis. When the radiological site of lesions was in the posterior segments of the lung, tuberculosis was the most probable diagnosis, while bronchogenic carcinoma is most oftenly localized in the anterior segments; only in 5 cases of the Author's series the above mentioned criterion was not satisfied. In 46 cases with clinical signs of inactive tuberculous disease which had not been adequately treated with chemotherapy, isoniazid was given only to those patients with a high risk of reactivation (silicosis, diabetes, chronic alcholism, gastric resection, prolonged steroid therapy). Two cases of isoniazid hepatitis were observed among patients treated by the Authors.