Causes and correlates of anemia in 200 patients with acute cardiogenic pulmonary edema.

BACKGROUND: Acute heart failure has a poor prognosis and the presence of anemia may increase the risk of adverse outcomes. However, the clinical and laboratory characteristics of anemia in acute heart failure are poorly known. We aimed to assess the causes and the clinical and laboratory correlates of anemia in patients with acute cardiogenic pulmonary edema (ACPE). METHODS: This observational study, performed in an Emergency Unit, enrolled 200 patients treated with medical therapy and continuous positive airway pressure. RESULTS: Anemia was found in 36% of patients (38.5% of females and 32.5% of males) and was severe (hemoglobin <9 g/dL) in 6.9% of cases. The most frequent causes of anemia were chronic renal failure (27.8%), chronic inflammatory states (27.8%) and the clustering of multiple factors (18.1%). A wider spectrum of etiological factors was found in females than in males. Microcytic anemia was observed only in females (20% of those anemic), mainly due to iron deficiency/chronic blood loss. Glomerular filtration rate, serum iron, serum albumin, total cholesterol and diastolic blood pressure were independently associated with hemoglobin levels. CONCLUSIONS: The etiology of anemia in ACPE is heterogeneous, with several causal factors besides impaired renal function. The pattern of anemia is different between genders, suggesting that sex-specific diagnostic and therapeutic targets should be implemented.

Atrial fibrillation in emergency department: prevalence of sinus rhythm 1 week after discharge.

BACKGROUND: Current guidelines do not provide definitive indications about the treatment in emergency departments (ED) of patients with recent-onset atrial fibrillation (AF). METHODS: A multicentre observational study involving four general hospitals of the same metropolitan area was conducted. All consecutive adult patients admitted to the ED with recent symptoms of AF (<48 h duration) and discharged home were considered. Patients who underwent ED early cardioversion were enrolled in group A. Patients managed with ventricular rate control were enrolled in group B. RESULTS: On the 24 h Holter recordings at 1-week follow-up, stable sinus rhythm was detected in 46/58 (79.3%; 95% CI 68.9 to 89.7) patients in group A and 8/33 (24.2%; 95% CI 9.6 to 38.9) patients in group B (p<0.01). CONCLUSION: According to the study results, rhythm at the time of ED discharge is a poor indicator of the short-term evolution of AF.

Thromboembolic and haemorrhagic events in permanent atrial fibrillation: observational study in an emergency department.

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia in patients admitted to Emergency Departments. However, the management of permanent AF in order to prevent thromboembolism in clinical practice is still widely discussed. We aimed to evaluate this management and the occurrence of clinical events in a cohort of patients with permanent AF admitted to our Emergency Department. METHODS: We enrolled in this observational study 582 patients with permanent AF consecutively seen in our Emergency Room. RESULTS: Mean age was 80.1 +/- 9.6 years. Two or more comorbidities were present in 67% of patients. 28% of patients were treated with oral anticoagulant therapy (OT) at the time of admission to the Emergency Department, 34.2% with anti-platelet therapy (APT), while 37.8% were taking no anti-thrombotic therapy. There was no correspondence between three observed groups of treatment and the risk stratification according to CHADS2. In the groups of patients at high or intermediate risk a higher number of ischemic stroke was observed in patients taking APT than in OT patients (16.1% vs 31.5%, p=0.001). A low frequency of total and cerebral haemorrhagic events was observed in all groups. Only the non severe bleeds were significantly more frequent in patients on OT. CONCLUSIONS: OT is well-tolerated even in elderly patients, with a low rate of haemorrhagic events. In clinical practice OT is underused, in particular in older patients, in spite of a high number of thrombotic events.

Prevalence of filariasis in symptomatic patients in Moyen Chari district, south of Chad.

Filarial parasites infect an estimated 140 million people worldwide. Wuchereria bancrofti, Onchocerca volvulus, Loa loa and Mansonella perstans are responsible for most filarial infections in sub-Saharan Africa. We describe the prevalence and the clinical characteristics of filariasis in symptomatic patients in Goundi Sanitary district:167 patients were enrolled (99 men, 68 women). M. perstans microfilariae were isolated in peripheral blood in 164 cases, while Loa loa and Wuchereria bancrofti filariasis were diagnosed in only six and three cases, respectively. The most frequent filariasis observed in our study were due to M. perstans and L. loa, while the few cases of W. bancrofti filariasis seem to have been acquired abroad. No cases of O. volvulus were observed. Microfilarial burden was not related to symptoms, but a correlation between eosinophilia and pruritus was evident. No relationship was observed between eosinophils and symptoms. The prevalence observed in symptomatic patients could reflect the real prevalence of filariasis.

Comparison of different anthelminthic drug regimens against Mansonella perstans filariasis.

Mansonella perstans filariasis is widely present in Africa and equatorial America and its pathogenicity has recently been reconsidered. Effective treatment is lacking and there is no consensus on the optimal therapeutic approach. The aim of this study was to compare the effects of different drug regimens on M. perstans infection. Six different anthelminthic therapeutic protocols were undertaken on 165 subjects with M. perstans infection and their effects on microfilariae burden were evaluated. Diethylcarbamazine (DEC) was able to reduce microfilariae density in the majority of cases, but it seldom eliminated infection after a single treatment. Mebendazole appeared to be more active than DEC in eliminating the infection, with a comparable rate of overall responses. Ivermectin and praziquantel showed no modification of microfilariae concentration. Thiabendazole showed a small but significant activity against the infection. Combination treatments (DEC plus mebendazole) resulted in a significantly higher activity than the single drugs.

Effects of simvastatin on blood pressure in hypercholesterolemic patients: An open-label study in patients with hypertension or normotension.

BACKGROUND: Simvastatin has been reported to improve endotheliumdependent vascular relaxation in patients with hypercholesterolemia. The consequent decrease in arterial stiffness might be associated with a decrease in blood pressure (BP). OBJECTIVE: The aim of this study was to determine whether simvastatin 20 and 40 mg/d have an effect on systolic and diastolic blood pressure (SBP and DBP, respectively) in patients with hypercholesterolemia, and, if so, whether the effect is dose dependent and/or is related to the changes in the serum lipid profile. METHODS: This 6-month, open-label study was conducted at the Lipid Clinics of the Department of Internal Medicine, University of Milan, Maggiore Hospital IRCCS, and of the Department of Internal Medicine 1, G. Salvini Hospital, Garbagnate Milanese (Milan, Italy). Patients aged 18 to 80 years with primary hypercholesterolemia who were following a low-fat, low-cholesterol diet for >2 months before the study were enrolled. Patients at high risk for cardiovascular disease (CVD), according to the National Cholesterol Education Program Adult Treatment Panel II guidelines, were given simvastatin 20 mg (tablet) QD for 3 months, and those at low risk for CVD continued with diet only for 3 months (controls). Efficacy variables included body weight, SBP, DBP, and serum lipid levels (total cholesterol [TC], low-density lipoprotein cholesterol [LDL-C], high density lipoprotein cholesterol [HDL-C], and triglycerides [TG]). At 3 months, patients in the simvastatin + diet group who reached their therapeutic goal continued to receive simvastatin 20 mg/d for 3 additional months. In simvastatintreated patients who were normotensive at baseline or who became normotensive at 3 months but who did not reach the therapeutic goal, the simvastatin dosage was increased to 40 mg/d. Patients in both groups who remained hypertensive at 3 months were switched to hypotensive therapy. In the diet-only group, patients who were formerly normotensive or who became normotensive at 3 months but who did not reach their therapeutic goal continued with diet only or started lipid-lowering therapy. All other patients in the diet-only group continued to be treated with diet only, for 3 additional months. Efficacy variables were measured again at 6 months. Tolerability of simvastatin was assessed at each visit using patient interview and measurement of serum aminotransferase and creatine phosphokinase levels. RESULTS: The study population comprised 222 patients (132 women, 90 men; mean [SEM] age, 53.9 [0.95] years [range, 23-76 years]); 115 high-risk patients (57 with untreated stage 1 hypertension) were assigned to the simvastatin + diet group, and 107 low-risk patients (29 with untreated stage 1 hypertension) were assigned to the diet-only group. In the simvastatin group, after 3 months of therapy, mean SBP was decreased by 3.9 (1.49) mm Hg (change, -2.9%), mean DBP decreased by 3.0 (0.87) mm Hg (change, -3.7%), mean TC decreased by 90.6 (3.98) mg/dL (change, -27.0%), mean LDL-C decreased by 88.9 (3.88) mg/dL (change, -35.6%), and mean TG decreased by 26.3 (7.34) mg/dL (change, -15.8%) (all, P < 0.001). Mean HDL-C increased by 3.6 (1.16) mg/dL (change, 6.9%; P < 0.001). The BP-lowering effect was found only in patients with hypertension at baseline (n = 57); in these patients, mean SBP decreased by 7.2 (2.44) mm Hg (change, -4.8%; P < 0.005 vs baseline) and DBP decreased by 4.8 (1.29) mm Hg (change, -5.6%; P < 0.001 vs baseline). Also in the simvastatin group, 26 patients (22.6%) achieved their target SBP/DBP. In patients with normotension at baseline (n = 58), neither SBP nor DBP was changed significantly (changes, -0.8 [1.65] and -1.4 [1.15] mm Hg, respectively [-0.6% and -1.8%, respectively]). The changes in serum lipid levels were similar between hypertensive and normotensive patients in the simvastatin group. Forty-one patients (18 hypertensive and 23 normotensive at baseline) were treated with simvastatin 40 mg/d plus diet between months 3 and 6. At 6 months, no further significant decrease was observed in mean BP. In contrast, the expected dose-dependent response was observed for TC and LDL-C levels. In the diet-only group, no significant changes occurred in BP or serum lipid levels. Changes in BP, TC, LDL-C, TG, and HDL-C were significantly greater in the simvastatin + diet group than in the diet-only group (all, P < 0.001). Body weight did not change significantly in either group. CONCLUSIONS: In this group of patients with hypercholesterolemia, the starting dosage of simvastatin (20 mg/d) was associated with reductions in SBP and DBP within 3 months of treatment in patients with hypertension, and this effect was independent of the lipid-lowering properties of the drug. Although the decrease in BP was modest, it is likely clinically relevant. Further studies on this topic are advisable.

Case report: intraocular localization of Mansonella perstans in a patient from south Chad.

A case of Mansonella perstans infection with visual impairment and a retinal lesion is described. After a course of diethylcarbamazine and a further course of mebendazole the symptoms improved and the microfilariae blood concentration decreased. The symptoms and response to antifilarial treatment strongly suggested the intraocular localization of an M. perstans worm.