Cardiogenic Shock during First Infusion of Anthracycline Chemotherapy in a Patient with Hodgkin Lymphoma: An Unusual Event.

INTRODUCTION: Hodgkin lymphoma (HL) is one of the most common types of cancers of the lymphatic system. The currently available therapies enable a cure in approximately 80-85% of treated patients. However, the cardiotoxicity of HL treatment has become a major cause of morbidity and mortality in survivors mainly related to the use of anthracycline. CASE REPORT: An HL, staged IIIB, was diagnosed in a 60-year-old man with no cardiovascular disease. During the first cycle of ABVD chemotherapy (Adriamycin; bleomycin; vinblastine; dacarbazine), near the end of the dacarbazine infusion, the patient presented a sudden cardiogenic shock characterized by a severe left ventricular systolic dysfunction. Laboratory and instrumental examinations performed did not suggest any specific etiology. After 15 days of medical support, the patient presented a complete cardiac function and clinical recovery. Subsequently bendamustine chemotherapy was started because of its limited extrahematological toxicity, but after 4 cycles the patient had progressive disease and died of septic shock. We concluded that a very rare hyperacute anthracycline cardiotoxicity was the most likely reason for this critical scenario. CONCLUSIONS: This rare event stresses our inability to correctly predict the risk of a patient developing cardiotoxicity and also highlights the need to improve the knowledge of underlying pathophysiological mechanisms; in fact, it suggests a possible genetic predisposition to develop cardiotoxicity due to a relatively limited dosage.

[The network for acute coronary syndromes in the metropolitan area of Cagliari (Italy): management of ST-elevation myocardial infarction, reperfusion time, and adherence to guidelines]. / La rete per l'emergenza coronarica nell'Area Vasta di Cagliari: gestione dell'infarto miocardico acuto con sopraslivellamento del tratto ST, analisi dei tempi di riperfusione e aderenza alle linee guida.

BACKGROUND: An integrated network for the management of acute ST-elevation myocardial infarction (STEMI) allows a pre-hospital diagnosis and facilitates the best strategy to provide the most effective reperfusion therapy. This study aims to assess the network impact on timing and mode of reperfusion in the metropolitan area of Cagliari. METHODS: From January 1, 2008 to December 31, 2010 all patients affected by STEMI with symptom onset <12h were enrolled. We evaluated modality of hospital access, reperfusion therapies, and time for avoidable delay. The first medical contact-to-balloon time (FMC-to-balloon) was compared between patients without ECG transmission (No-ECG group) and those with ECG transmission and direct transport to the cath-lab (Cath-Lab-ECG group) or the emergency room/intensive cardiac care unit (ER/ICCU-ECG group). RESULTS: Out of 622 patients enrolled, 324 (52.1%) arrived to hospital by emergency medical systems. In this group a pre-hospital diagnosis was made in 79.3% of cases (n = 257); among them, 138 patients (53.7%) had a direct access to cath-lab, 99 to ICCU (38.5%), and 20 (7.8%) to ER. In the whole study population an urgent coronary angiography was performed in 612 patients (98.4%) and a primary percutaneous coronary intervention (p-PCI) in 589 (96.2%). In the Cath-Lab-ECG group the FMC-to-balloon was 89 ± 29 min (median 87 min, interquartile range 72-100), significantly lower than in the ER/ICCU-ECG group [122 ± 39 min (115 min)] and the No-ECG group [150 ± 54 min (139 min)] (p<0.01). A FMC-to-balloon ≤90 min was achieved in 66.4% of Cath-Lab-ECG patients, 22.1% of ER/ICCU-ECG patients, and 8.3% of No-ECG patients (Cath-Lab-ECG vs ER/ICCU-ECG, p<0.01). CONCLUSIONS: Our results show that an integrated network provides a pre-hospital diagnosis in the majority of STEMI. However, only a direct transport to the cath-lab allows to achieve a FMC-to-balloon ≤90 min in a large proportion of patients. Out of this condition, adherence to guideline-recommended time of ≤90 min is significantly lower.

Gingival crevicular fluid alkaline phosphatase activity reflects periodontal healing/recurrent inflammation phases in chronic periodontitis patients.

BACKGROUND: Roles for host enzymes as diagnostic indicators of periodontal status in gingival crevicular fluid (GCF) have been proposed. One of these host enzymes is alkaline phosphatase (ALP), the GCF activity of which has been associated with periodontal inflammation. Thus, the present study aimed to improve our understanding of how the healing of chronic periodontitis following scaling and root planing (SRP) affects GCF ALP activity after 15 and 60 days. METHODS: Sixteen systemically healthy subjects (aged 35 to 61 years) with moderate to advanced generalized chronic periodontitis were recruited. In each subject, paired pockets with probing depths (PDs) > or =4 mm that were located in two symmetric quadrants were chosen. These sites were randomized at the split-mouth level, with half receiving SRP treatment and the other half left untreated. Ninety-two pockets were included in the study. Clinical examinations were performed at baseline (prior to SRP) and after 15 and 60 days; information recorded included the presence of plaque, PD, clinical attachment level (CAL), and bleeding on probing. GCF was collected from each pocket included in the study at the three time points. RESULTS: A large and significant decrease in GCF ALP activity was seen 15 days after SRP, concomitant with an improvement in clinical parameters. After 60 days, an increase in GCF ALP activity back to baseline levels was recorded along with further improvements in clinical parameters. Moreover, in the SRP pockets with initial PDs >6 mm, the CAL gains between days 15 and 60 were significantly associated with changes in GCF ALP activity over the same time interval. CONCLUSIONS: The decrease in GCF ALP activity at 15 days corresponded to a decrease in clinical signs of inflammation; in contrast, the increase in GCF ALP activity at 60 days seemed to be related to subclinical recurrent inflammation or further healing/remodeling of the periodontal tissue. Therefore, GCF ALP reflects the short-term periodontal healing/recurrent inflammation phases in chronic periodontitis patients.

Effects of combined deferiprone and desferrioxamine iron chelating therapy in beta-thalassemia major end-stage heart failure: a case report.

Despite usual iron chelating therapy based on desferrioxamine, patients affected by beta-thalassemia major (beta-TM) often develop progressive heart failure caused by myocardial iron overload, which is the leading cause of mortality within the third decade of life. Heart transplantation is a limited therapeutic option, as very often these patients have multi-organ iron deposits and infective complications (particularly hepatitis C), secondary to frequent blood transfusions. We report the case of a 26-year-old male affected by beta-TM with end-stage heart failure, who showed a dramatic improvement in symptoms and myocardial function when a new oral iron chelating agent, deferiprone, was added to standard therapy with desferrioxamine.

Lactate dehydrogenase activity in human gingival crevicular fluid during orthodontic treatment: a controlled, short-term longitudinal study.

BACKGROUND: During orthodontic tooth movement, the early response of periodontal tissues to mechanical stress is an acute inflammatory one. This study uses a longitudinal design to examine lactate dehydrogenase (LDH) activity in gingival crevicular fluid (GCF) to determine if GCF LDH can be used as a diagnostic aid in monitoring tooth movement and tissue response during orthodontic treatment. METHODS: Seventeen patients (mean age: 16.1 years) participated in the study. Each patient was undergoing treatment for distal movement, and an upper first molar served as the test tooth (TT), while the contralateral (CT) and antagonist (AT) teeth were used as controls. The CT was included in the orthodontic appliance, but was not subjected to the distal movement; the AT was free from any orthodontic appliance. The GCF around the experimental teeth was harvested from both mesial and distal tooth sites immediately before appliance activation, and on days 7, 14, and 21. Clinical gingival conditions were also recorded. RESULTS: Gingival crevicular fluid LDH activity was significantly elevated in all sites of the TT and CT, as compared to the AT, where LDH activity remained at the baseline level throughout the study. Enzyme activity levels were also greater in the TT than in the CT, and in the compression sites. CONCLUSIONS: Our results suggest that GCF LDH levels reflect the biological activity that takes place in the periodontium during orthodontic movement, and therefore they can be used as a diagnostic tool for monitoring for correct orthodontic tooth movement in clinical practice.

Longitudinal monitoring of subgingival colonization by Actinobacillus actinomycetemcomitans, and crevicular alkaline phosphatase and aspartate aminotransferase activities around orthodontically treated teeth.

OBJECTIVES: During orthodontic treatment, changes in subgingival plaque colonization and tissue inflammation and remodelling have been described. This study uses a longitudinal design to examine subgingival colonization of Actinobacillus actinomycetemcomitans (Aa) and alkaline phosphatase (ALP) and aspartate aminotransferase (AST) activities in gingival crevicular fluid (GCF) in order to assess whether these parameters have potential as biomarkers of tissue responses to orthodontic tooth movement in humans. MATERIALS & METHODS: Twenty-one patients (ages: 11.2-22.5; mean 17.1 +/- 3.3 years) participated in the study. An upper canine from each patient undergoing treatment for distal movement served as the test tooth (DC), and its contralateral (CC) and antagonist (AC) canines were used as controls. The CC was included in the orthodontic appliance, but was not subjected to the orthodontic force; the AC was free from any orthodontic appliance. The subgingival plaque and GCF around the experimental teeth was harvested from both mesial and distal tooth sites immediately before appliance activation and on day 28. Clinical gingival condition was evaluated at the baseline and at the end of the experimental period. Aa colonization was determined by culture methods, while ALP and AST activities were evaluated spectrophotometrically. RESULTS: Throughout the study, the clinical conditions worsened in both the DCs and the CCs as compared with the baseline, whereas no significant differences were found between the DCs and the CCs, or between mesial and distal sites of each of these teeth on day 28. In the ACs, clinical parameters remained at baseline levels throughout the study. Similar results were found for Aa colonization, which increased significantly on day 28 in the DC and CC groups. On day 28, ALP and AST activities were significantly elevated in all sites from the DC and CC groups as compared with the ACs, where, conversely, enzymatic activities remained at the baseline levels. However, ALP activity in the DC group was significantly greater than in the CCs at mesial (tension) sites on day 28, while AST activity in the DCs was significantly elevated as compared with the CC group at the distal (compression) sites. Greater ALP activity in the DC group was observed at the tension sites compared with the compression sites on day 28. CONCLUSIONS: Our results suggest that Aa subgingival colonization, and ALP and AST activities in GCF reflect the tissue responses that occur in the periodontium during orthodontic treatment.

Clinical and microbiological effects of different restorative materials on the periodontal tissues adjacent to subgingival class V restorations.

OBJECTIVES: The relationship between subgingival dental restorations and periodontal health has been thoroughly investigated for many years. However, longitudinal data on the subgingival microflora features after the placement of well-finished subgingival restorations are still lacking. Therefore, this study compares the short-term clinical and microbiological features occurring in the gingiva after the completion of different subgingival restorations. MATERIAL AND METHODS: Sixteen systemically healthy subjects, 10 males and six females (ages: 31.7-45.8 years; mean age 39.3+/-5.1 years), who were non-smokers and were positive for the presence of three cervical abrasion/erosion defects to be restored in three different adjacent teeth were enrolled in this study. The cervical abrasion/erosion defects were each restored by using one of three different materials: amalgam, glass ionomer cement, or composite resin. Immediately before class V cavity preparations and restorations (baseline), clinical monitoring and subgingival plaque sampling were performed in the mid-buccal aspect of each experimental restored tooth and in one adjacent sound, non-treated, control tooth. These procedures were repeated every 4 months over the following 1 year. RESULTS: Throughout the study, the clinical parameters recorded did not change significantly in any of the experimental groups, and no differences were detected among them at each clinical session. Over this time, no significant changes in the composition of the subgingival microflora were observed in amalgam, glass ionomer cement, and control groups. Conversely, in the composite resin group, there was a significant increase in the total bacterial counts, and a significant (p<0.05) decrease in Gram-positive, aerobic bacteria, which was associated with a significant (p<0.05) increase in the Gram-negative, anaerobic microbiota. CONCLUSIONS: Over a 1-year observation period, amalgam, glass ionomer cement, and composite resin subgingival restorations do not significantly affect the clinical parameters recorded. However, composite resin restorations may have some negative effects on the quantity and quality of subgingival plaque.

Clinical and microbiological effects of subgingival administration of two active gels on persistent pockets of chronic periodontitis patients.

OBJECTIVES: The present controlled, single-blind study was performed to assess and compare the clinical healing and the microbiological findings following repeated intrasulcular applications of 1% metronidazole or 1% chlorhexidine gels in persistent periodontal pockets previously treated by scaling and root planing (SRP). MATERIAL AND METHODS: Sixty-three systemically healthy subjects, 25 males and 38 females (mean age 48.4+/-7.2 years), diagnosed for chronic periodontitis were enrolled in this study. They underwent SRP and received oral hygiene instructions (OHI). Three months later, at baseline, a single persistent pocket with a probing depth (PD) of 5-9 mm was chosen as the experimental site in each patient; the subjects were stratified into three matched experimental groups on the basis of the treatment to be performed, which consisted of the subgingival administration of 1% metronidazole gel (MG, n=19), 1% chlorhexidine gel (CG, n=20) or placebo gel (PG, n=24). The treatments consisted of four repeated administrations of subgingival gels, each separated by 7 days, starting at the baseline. Clinical assessment was performed at the baseline and at the 180-day follow-up, after the end of treatment. For microbiological evaluations, subgingival plaque was sampled from the experimental sites at baseline, prior to the first subgingival gel administration, and at 7, 15, 30 and 90 days after the end of the treatment (days 28, 36, 51 and 111 from baseline). RESULTS: Plaque accumulation did not change significantly in all three groups. Bleeding on probing and clinical attachment levels reduced in the MGs and CGs only. PD was significantly reduced by the same amount in all experimental groups. In the MGs and CGs a remarkable reduction in the frequencies of detection of several periodontopathic micoorganisms was recorded after the treatment. The same was not seen for the PGs. CONCLUSIONS: Subgingival administration of MG or CG, both at 1%, may have a role in the management of persistent pockets during chronic periodontitis.

Lactate dehydrogenase activity in gingival crevicular fluid during orthodontic treatment.

During orthodontic treatment, the early response of periodontal tissues to mechanical stress involves several metabolic changes that allow tooth movement. Many studies have evaluated such modifications by analysis of various host metabolites released into the gingival crevicular fluid (GCF). This study used a cross-sectional design to examine the lactate dehydrogenase (LDH) activity in GCF to assess whether GCF LDH can be proposed as a sensitive marker for periodontal tissue modifications during orthodontic tooth movement. Thirty-seven subjects, 16 males and 21 females (mean age 18.7 years, range 14.0 to 26.7 years), participated in this study. Each subject underwent a session of professional oral hygiene and received oral hygiene instructions; 2 weeks later, a fixed orthodontic appliance was placed on the maxillary arch. A randomly selected maxillary canine was considered as the test tooth, and its antagonist, which had no appliance, was used as the control tooth. From 2 to 12 weeks after orthodontic appliance placement, GCF was harvested from both experimental teeth at the mesiobuccal angle, for GCF volume and LDH activity determinations. Clinical monitoring consisted of recording supragingival plaque presence, bleeding on probing, and probing depth at the same collection sites. The results showed that no differences in clinical conditions and GCF volume occurred between the experimental teeth. On the contrary, GCF LDH activity in the test teeth was significantly greater than that of the control teeth (P <.01). Moreover, no differences were found in the enzymatic activity between the sexes by experimental tooth, and no significant correlation was present between GCF LDH activity and patients' ages within experimental teeth. Our enzymatic results initially indicated a possible role of GCF LDH during the early phases of orthodontic treatment and therefore warrant further study as a possible diagnostic tool for tissue response during orthodontic treatment.