What are the differences between younger and older patients with symptomatic small vessel disease?

Objective

Although typically linked to aging, small vessel disease (SVD) is also observed in younger adult patients, with common vascular risk factors (RF). We aimed to investigate features of SVD occurrence at an early adult age.

Patients and methods

Vascular RF, functional and cognitive status and severity of lesions on MRI expressed as total score on Age-Related White Matter Changes (ARWMC) scale were analyzed in 200 consecutive patients with cerebral SVD admitted to a tertiary neurological hospital. Variables were compared between younger (35–55 years) and older (>56 years) patients.

Results

In this study, 63 (31.5%) of patients were 55 years or younger. Both age groups had comparable RF profiles, but smoking emerged as an independent predictor for SVD at a younger age (OR 2.9; 95% CI 1.5–5.5; p = 0.002). Younger patients had better functional (OR 1.8; 95% CI 1.3–2.5; p = 0.0001) and cognitive (χ² 13.94; p = 0.0009) status compared to older patients. However, two thirds of younger patients had some degree of cognitive deficit. Total score on ARWMC scale was lower in younger patients (mean 12.3 in younger versus 15.2 in older, OR 1.11; 95% CI 1.0–1.18; p = 0.001). There was a strong correlation in both groups between functional score, cognitive status and ARWMC score (p < 0.0001).

Conclusion

In our dataset, younger patients with SVD shared common vascular RF with older patients. In the group aged ≤55, better functional and cognitive status and less severe MRI changes were noted. However, a substantial number of younger SVD patients presenting with TIA or ischemic stroke had various deficits.     

Efficacy of intravenous magnesium sulfate in severe migraine attacks

The aim of this open study was to make a preliminary estimate of the efficacy and tolerability of intravenously administered magnesium sulfate (1 g) in comparison to subcutaneously administered sumatriptan in the treatment of severe migraine attacks. The study comprised 22 consecutive patients whose attacks were treated with magnesium sulfate (5 ml of a 20% solution), and the results were compared with those of another group of 14 consecutive patients whose attacks were treated with sumatriptan (6 mg). Immediately before and 10, 20 and 30 minutes after injections, patients reported pain intensity on a verbal 0–10 scale. Pain disappearance or pain relief >50% were considered significant. Efficacy of sumatriptan was superior that of to magnesium sulfate 20 minutes after the injections (p<0.05) and comparable after 30 minutes (magnesium therapy was successful in 68% in comparison to 79% of patients treated with sumatriptan). After only 10 minutes, 3 patients treated with magnesium sulfate were pain free, with the same effect in 5 (22.5%) and 10 (45%) patients after 20 and 30 minutes, respectively. The rate of headache recurrence was low and no major adverse effects were recorded. In conclusion, magnesium sulfate may be a well-tolerated pharmacological alternative for the treatment of severe migraine attacks. Received: 12 January 2001 / Accepted in revised form: 6 July 2001     

Aplitic Granite Waste as Raw Material for the Production of Outdoor Ceramic Floor Tiles

One of the significant problems in the production of ceramic tiles is the very high consumption of natural resources such as clay, feldspar, and quartz. The possibility of replacing part of the formulation of ceramic batches is of great importance. In this research, the possibility of using aplitic granite waste from dimensional stone production was analyzed in detail. The waste is considered a low-cost substitute for feldspar in Serbia. The milled powdery waste was analytically tested to reveal its chemical and mineralogical contents, particle size distribution, and other important properties. The ceramic tiles containing aplitic granite waste (GW) and GW/raw clay mixture (CGW) were hydraulically pressed, and the ceramic and technological properties determined. This waste can act as a filler while forming, drying, and firing, since the high content of quartz helps to control the shrinkage and acts as a fluxing agent in high temperatures due to its feldspathic nature. The waste was found favorable in the production of ceramic tiles, as the gained values of modulus of rupture and water absorption were 28.68 MPa and 1.33%, respectively. The parameters defined in the series of standards EN ISO 10545 were tested on a semi-industrial probe, determining that this combination of materials (without the addition of quartz) may be efficiently used to produce ceramic floor tiles. The usage of what would otherwise be waste material contributes to sustainable management and environmentally friendly solutions by avoiding landfilling, while at the same time it enabling the conservation of scarce natural feldspar deposits.     

N-Terminal Prohormone of Brain Natriuretic Peptide (NT-proBNP) as a Diagnostic Biomarker of Left Ventricular Systolic Dysfunction in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD)

Introduction

Left ventricular systolic dysfunction (LVSD) and cardiac decompensation often accompany AECOPD. Differentiation between the two is difficult and mainly relies on clinical and echocardiographic diagnostic procedures. The value of biomarkers, such as NT-proBNP, as diagnostic tools is still insufficiently investigated. The main goals of this trial were to investigate the value of NT-proBNP as a diagnostic tool for LVSD in AECOPD patients and determine its cut-off value which could reliably diagnose LVSD during AECOPD.

Patients and Methods

This trial prospectively enrolled 209 patients with AECOPD. The patients were divided into four groups—AECOPD plus chronic pulmonary heart disease (CPHD) with or without left ventricular compromise (LVSD), and AECOPD patients without CPHD with or without LVSD. NT-proBNP was measured within first 48 h of hospitalization.

Results

Majority of patients were male (61%) active smokers (41.6%), average age of 68 years. High quality of echocardiography was obtained in 63.3 and 22.5% of the patients had LVSD. Average value of NT-proBNP in patients with LVSD was 3303.2 vs. 1092.5 pg/mL in patients without LVSD. Significant differences in NT-proBNP value (p?=?0.0001) were determined between observed patient groups. At the cut-off value of 1505 pg/mL, sensitivity, specificity, and positive and negative predictive values are 76.6, 83.3, 57.1, and 92.47%, respectively.

Conclusion

At the cut-off value of 1505 pg/mL NT-proBNP could be used as a diagnostic marker for LVSD in acute exacerbation of COPD.

     

Cerebral small vessel disease in pseudoxanthoma elasticum: three cases

BACKGROUND: Cerebral small vessel disease is rarely described in association with pseudoxanthoma elasticum (PXE), a hereditary connective tissue disorder with skin, eye and vascular manifestations. This autosomally inherited elastic tissue disease has been attributed to mutations in the ABCC6 gene located on chromosome 16p13.1. Different stroke mechanisms are suggested in PXE patients, arterial hypertension and accelerated atherosclerosis being the leading ones. CASE DESCRIPTIONS: Case 1: A 49-year-old man with history of mild hypertension presented with recurrent transient ischemic attacks. At the age of 42, evaluation for progressive visual loss and skin changes led to diagnosis of PXE. Brain magnetic resonance imaging (MRI) disclosed multiple lacunar infarctions and confluent periventricular white matter lesions (WML). Case 2: A 71-year-old woman with history of mild hypertension suffered right-sided stroke. Diagnosis of PXE was made at the age of 48 due to severe visual loss and skin changes. Brain MRI revealed multiple lacunar infarctions and subcortical ischemic leukoencephalopathy. Case 3: A 47-year-old woman with prominent skin changes and bilateral amblyopia developed right-sided weakness. Skin biopsy confirmed PXE. Several lacunar infarcts in deep white matter and pons were revealed on MRI. DISCUSSION: We present three patients with clinical and histopathological features of PXE who presented with multiple lacunar strokes, two with extensive confluent WML. These cases illustrate that PXE is a rare but significant risk factor for small vessel disease and stroke in patients of all age groups. Occlusive small vessel disease and subsequent lacunar infarcts and WML represent important PXE manifestations.     

Progressive form of pulmonary Langenharns' cell histiocytosis in a female adult non-smoker

Little is known about the cause, nature, treatment and prognosis of pulmonary Langerhans' cell histiocytosis (LCH) in adults. We report the case of a 44-year-old female non-smoker suffering from pulmonary histiocytosis who after a 7-year remission period relapsed with both lung and bone disease. Using a combination of corticosteroids, methotrexate and bone irradiation treatment, the patient achieved total disease remission. The patient was a non-smoking female who has had long-term and swift remission of the disease on two occasions.     

Heart Rate Recovery after Submaximal Exercise in Four Different Recovery Protocols in Male Athletes and Non-Athletes

The effects of different recovery protocols on heart rate recovery (HRR) trend through fitted heart rate (HR) decay curves were assessed. Twenty one trained male athletes and 19 sedentary male students performed a submaximal cycle exercise test on four occasions followed by 5 min: 1) inactive recovery in the upright seated position, 2) active (cycling) recovery in the upright seated position, 3) supine position, and 4) supine position with elevated legs. The HRR was assessed as the difference between the peak exercise HR and the HR recorded following 60 seconds of recovery (HRR₆₀). Additionally the time constant decay was obtained by fitting the 5 minute post-exercise HRR into a first-order exponential curve. Within- subject differences of HRR₆₀ for all recovery protocols in both groups were significant (p < 0. 001) except for the two supine positions (p > 0.05). Values of HRR₆₀ were larger in the group of athletes for all conditions (p < 0.001). The time constant of HR decay showed within-subject differences for all recovery conditions in both groups (p < 0.01) except for the two supine positions (p > 0.05). Between group difference was found for active recovery in the seated position and the supine position with elevated legs (p < 0.05). We conclude that the supine position with or without elevated legs accelerated HRR compared with the two seated positions. Active recovery in the seated upright position was associated with slower HRR compared with inactive recovery in the same position. The HRR in athletes was accelerated in the supine position with elevated legs and with active recovery in the seated position compared with non-athletes.

Key points

• In order to return to a pre-exercise value following exercise, heart rate (HR) is mediated by changes in the autonomic nervous system but the underlying mechanisms governing these changes are not well understood.
• Even though HRR is slower with active recovery, lactate elimination after high intensity exercise might be more important for athletes than the de-cline of heart rate.
• Lying supine during recovery after exercise may be an effective means of transiently restoring HR and vagal modulation and a safe position for prevention of syncope.

Key words: Heart rate recovery, autonomic activity, active recovery, physical activity     

Early pregnancy angiogenic proteins levels and pregnancy related hypertensive disorders

Introduction: Normal placental vascular development depends on multiple interactions of many regulatory molecules including pro and antiangiogenic proteins. It is considered that these vascular modulators might be one of the factors responsible for development hypertensive disorders in pregnancy.

Objective: To evaluate and compare the early pregnancy (11–14 week of gestation) serum level of angiogenic proteins sFlt1, VEGF i PIGF between different types of pregnancy related hypertensive disorders.

Materials and methods: The study included 177 pregnant women between 11 and 14 weeks of gestation, divided into four study subgroups (preeclampsia group-41, gestational hypertension group-31, chronic hypertension group-32 and miscarriage group-19) and control group-54. Blood samples (serum) were taken for measuring sFlt1, VEGF i PIGF by a quantitative ELISA technique and measuring other biochemical and hematological parameters.

Results: Significantly higher levels of sFlt1 were in the subgroups with preeclampsia and miscarriages, significantly lower level of VEGF in the all study subgroups and lover level of PIGF were in miscarriage group. In the groups with chronic and gestational hypertension there were higher level of sFlt1 and lover level of VEGF than in the control group, but the differences did not reach statistical significance.

Conclusion: Early pregnancy imbalance between antiangiogenic protein sFlt1 and proangiogenic molecules VEGF and PIGF could have impact on pathophysiology of placental disorders which leads to development of pregnancy related hypertensive disorders.