Methods of investigating orthostatic hypotension]

Orthostatic hypotension, which is common mainly in the elderly, is in many cases related to hypovolemia and/or vasodilators intake. However, when an impairment of the autonomic nervous system is suspected, orthostatic hypotension severity and mechanism may be investigated. The most common tests are the head upright tilt-test and the Valsalva manoeuvre. Both of them examine the baroreflex system as a whole, and become non invasive tests with the development of finger arterial blood pressure continuous measurement. Each part of the baroreflex system may be investigated separately. So, cardiac vagal responses to ocular compression, to carotid sinus massage, to respiratory change or to atropine infusion, may be tested. On the other hand, sympathetic efferent pathways may be stimulated in a variety of ways, such as isometric exercise, cutaneous cold, mental arithmetic, norepinephrine infusion, or tiltest. None of these tests should be applied systematically, but according to the clinical features.     

Musculoskeletal manifestations of endocrine disorders

PURPOSE OF REVIEW: Much of our education about endocrine disorders focuses on their diagnosis and treatment. Although the musculoskeletal manifestations of endocrine disorders are well documented, they are often overlooked. This review will discuss new developments regarding those rheumatic manifestations. RECENT FINDINGS: Diabetic research is investigating connective tissue alterations in hand syndromes. A recent review elucidated the natural history of diabetic muscle infarction. Research has identified factors that stimulate osteoblast activity in diffuse idiopathic skeletal hyperostosis and bone loss in diabetics. Accumulating evidence documents thyroid disease coexisting with connective tissue disorders. Reports document cases of vasculitis occurring after propylthiouracil treatment. Finally, data clarifies the effects of thyroid dysfunction, hyperparathyroidism, acromegaly and hypercortisolism on bone. SUMMARY: Current research mainly relates to the effects of endocrine disorders on bone. As we advance our understanding of mechanisms that lead to rheumatic disorders in endocrine disease, we will improve our ability to treat them.     

Cinética temprana de troponina en pacientes con sospecha de infarto agudo de miocardio

Introduction and objectivesRelease kinetics of high-sensitivity cardiac troponin (hs-cTn) T and I in patients with acute myocardial infarction (AMI) are incompletely understood. We aimed to assess whether hs-cTnT/I release in early AMI is near linear.MethodsIn a prospective diagnostic multicenter study the acute release of hs-cTnT and hs-cTnI within 1 and 2 hours from presentation to the emergency department was quantified using 3 hs-cTnT/I assays in patients with suspected AMI. The primary endpoint was correlation between hs-cTn changes from presentation to 1 hour vs changes from presentation to 2 hours, among all AMI patients and different prespecified subgroups. The final diagnosis was adjudicated by 2 independent cardiologists, based on serial hs-cTnT from the serial study blood samples and additional locally measured hs-cTn values.ResultsAmong 2437 patients with complete hs-cTnT data, AMI was the adjudicated diagnosis in 376 patients (15%). For hs-cTnT, the correlation coefficient between 0- to 1-hour change and 0- to 2 hour change was 0.931 (95%CI, 0.916-0.944), P < .001. Similar findings were obtained with hs-cTnI (Architect) with correlation coefficients between 0- to 1-hour change and 0- to 2 hour change of 0.969 and hs-cTnI (Centaur) of 0.934 (P < .001 for both). Findings were consistent among type 1 and type 2 AMI and in the subgroup of patients presenting very early after chest pain onset.ConclusionsPatients presenting with early AMI showed a near linear release of hs-cTnT and hs-cTnI. This near linearity provides the pathophysiological basis for rapid diagnostic algorithms using 0- to 1-hour changes as surrogates for 0- to 2 hour or 0- to 3 hour changes.Registered at ClinicalTrials.gov (Identifier: NCT00470587).     

Respiratory insufficiency and limb muscle weakness in adults with Pompe's disease.

The objective of the present study was to prospectively evaluate relationships linking age, respiratory function and locomotor function in 29 outpatients with late-onset Pompe's disease and to retrospectively determine clinical outcomes. Using univariate regression analysis, vital capacity (VC) was weakly, but significantly, correlated to shoulder motility, Walton score and lower-limb Modified Medical Research Council score. Six patients were able to walk without a walking aid and with only the help of a handrail on the stairs (Walton score=3), although VC was <50%. No parameters were significantly correlated with age. As assessed retrospectively, VC and locomotion deteriorated over time in most patients. In contrast, among the 16 patients started on invasive or noninvasive ventilation with VC monitoring, eight had a VC increase at the first measurement time-point. The absence of correlation with age and the presence, in some patients, of severe respiratory insufficiency without severe limb girdle muscle weakness indicate that respiratory function should be monitored independently from the degree of peripheral muscle weakness. Mechanical ventilation and tracheostomy may improve vital capacity and should, therefore, be taken into account when evaluating treatments for the adult form of Pompe's disease.     

Adverse effects of intravenous lignocaine therapy in fibromyalgia syndrome

SIR, Fibromyalgia is poorly understood in neurobiological terms,with no general agreement about its aetiology and pathogenesis.The symmetry of the condition leads to the hypothesis of a centralnervous system disturbance [1]. In neuropathic pain states,it has been shown that inhibition of the pain pathway can beachieved by systemic administration of local anaesthetics suchas intravenous lignocaine [2, 3].     

Reduction in tissue blood flow in J-shaped pelvic ileal reservoirs

PURPOSE: This study sought to evaluate tissue blood flow during J-shaped ileal reservoir construction. METHODS: Using laser Doppler flowmetry, tissue blood flow was measured at various locations in J-shaped ileal reservoirs constructed in 10 dogs before pouch-anal anastomosis. For 12 weeks postoperatively, animals were assessed for clinical complications. In another five dogs, tissue blood flow was measured at various stages of J-pouch construction. RESULTS: Tissue blood flow in the reservoir was reduced and was lowest at the apex of the J. the site of clinical stricture in one animal. During reservoir construction, longitudinal enterotomy was associated with the greatest reduction in tissue blood flow. Lowest blood flow in the reservoir was at the site of the intended pouch-anal anastomosis (11.5±1.6 ml/100 g/min vs.43.4±3.4 ml/100 g/min (controls);P <0.05). CONCLUSIONS: Operative maneuvers of J-shaped ileal reservoir construction, particularly longitudinal enterotomy, significantly reduce tissue perfusion in the involved bowel segment. Tissue blood flow in the pouch is lowest at the site of intended pouch-anal anastomosis, and this may contribute to development of complications seen clinically.Supported in part by grants from the Department of Veterans Affairs and the National Foundation for Ileitis and Colitis.