[Erysipelothrix rhusiopathiae endocarditis]

Erysipelothrix rhusiopathiae is a thin, non-sporulating, gram-positive rod found worldwide and hosted by many domestic or savage animals, birds, fish, and shell/fish. It is extremely resistant in the external environment (soil, surface waters). Human infection is prevalently related to occupational exposure to sick or infected contaminated animals (anthropozoonosis). Frequently, the disease manifests itself as an acute cellulitis on the skin around the gate of entry. Systemic infection is uncommon, most commonly involving the endocardium or joints. We present a case of subacute E. rhusiopathiae endocarditis in a male patient at occupational hazard for this infection (animal genitor in a zoo). The patient was treated with cefoperazone, the course being favorable. Later on, he required mitral valvuloplasty.

[Some aspects of degenerative mitral valve lesions encountered in medical practice]

In recent years, degenerative valvular heart diseases have the tendency to be equal in frequency with rheumatic valvular diseases. The maximum attention has been paid on the degenerative aortic stenosis as being a lesion with maximum frequency and a severe evolution. This study, given on the 18,391 admissions in the period 1997-2001, is a retrospective analysis and it is concerned with the degenerative mitral valvular lesions. Of the 223 patients with degenerative valvular heart lesions, 139 patients (62.3%) had degenerative aortic stenosis and 96 patients (38.5%) were diagnosed with degenerative mitral valvular lesions from which 30 patients have had no association with aortic valvular lesions while 66 patients have had such an association. The pointed out types of mitral lesions were: the mitral insufficiency in 59 patients, the mitral annular calcification without hemodynamic disease in 19 patients, the mitral stenosis in 9 patients and the mitral disease in 9 patients, too. The women were affected nearly 1.7 times more frequent than the men, with a maximum average age greater with four years for women but with a low minimal average age at 60 years for women and 52 years for men. The detailed analysis of this 96 cases had shown the presence of a cholesterol value over 200 mg/dl in 50 patients (52%), the diabetes mellitus of type II in 12 patients (12.5%), an association with HTA in 42 patients (43.7%), the cardiac insufficiency in 68 patients (70.8%), a permanent atrial fibrillation in 24 patients (25%), chronic myocardial infarct in 19 patients (19.7%) and disorders in the transmission of stimuli in 8 patients (8.3%). The degenerative mitral valvular lesions had occurred more and more frequently realizing more complex features under the mitral insufficiency predominance. Its frequent association with the degenerative valvular lesions determines the evolutive and therapeutic particulars that are dominated by the high gravity prognostic.

[HDL-cholesterol--active or passive participant in the pathogenesis of atherosclerosis? (II)]

It is known that high sanguin levels of cholesterol and LDL-cholesterol (LDLc) have an important role in the pathogenesis of atherosclerosis. The treatment of hypercholesterolemia with statins and/or with fibrates have had beneficial effects on coronary heart disease and on other localization of atherosclerosis. The decreased of cholesterol and LDL-cholesterol is the most important effect of this treatment. The epidemiological studies have revealed that the treatment with statins and/or with fibrates produce an increase of HDL-cholesterol (HDLc), which is also very important in the regression of atherosclerosis. We tried in this review to explain the mechanisms of the increase of HDL-cholesterol, in concordance with the data from literature.

[Acute myocardial infarction with neurological symptoms: clinical and pathologic aspects]

A variety neurological symptoms can be the onset of an acute myocardial infarction. The study includes 96 patients who have undergone necropsies (from 1978 to 2003), hospitalized at the "Sfânta Treime" University Hospital, Iaşi, in the Neurology Clinic. They were admitted for various neurological manifestations: hemiparesis, hemiplegia, aphasia, coma of the 1st degree up to the 4th. Death of these patients was due to acute myocardial infarction in the cases of most of them, even those with significant brain damage. We have taken into account the anatomic pathology of the heart, brain, kidneys and lungs. The prevalence of the factors of cardiovascular risk was considered in our study, as well as the topography of the myocardial infarction. Patients with acute myocardial infarction can present major neurological symptoms with no significant cardiovascular clinical symptoms.

[Implications of some risk factors in degenerative valvular heart diseases]

A retrospective study on 223 patients diagnosed with degenerative heart valvular lesions: 124 women with an average of 74.9 years old and 99 men with an average of 70.1 years old with the lower limit under 50 years old (one woman and one man) and upper limit over 80 years old (22 women and 11 men) revealed that 109 patients (48.8%) had arterial hypertension, 30 patients (13.4%) had diabetes mellitus, and 16 patients (7%) had obesity. Chronic alcoholism was present at 89 patients (39.9%), chronic tobacco consumption at 54 patients (24.2%), cholesterol value over 200mg/dl in 99 patients (44%) and triglycerides value over 150 mg/dl in 15 patients (6.6%). In the 15 patients with a sever form of aortic stenosis was discovered cholesterol value over 200 mg/dl as well as chronic tobacco use and alcoholism.

CONCLUSION

Degenerative heart valvular disease represents a different process from arteriosclerosis, therefore the conventional risk factors of arteriosclerosis, can not be considered as having the same significance for degenerative heart diseases.

[Cardio-thoracic index: marker of the clinical course of alcoholic dilated cardiomyopathy]

Alcoholic cardiomyopathy (ACM), a principal form of secondary dilated cardiomyopathy, can ensue from heavy consumption of alcohol over a long period of time. In harmful consumption, alcohol and its metabolites has a toxic effect on heart muscle cells. The clinical features include dilatation of the left ventricle, poor myocardial contractility and symptoms of heart failure. The heart and lung X-ray examination is required in all disease stages. The information gathered from this cheap and noninvasive investigation method, are very important in the diagnosis algorithm. In the ACM stages beginning, before the installation of the heart failure symptoms, it is possible to found normal dimensions of the heart, which is compatible with the alcoholic cardiomyopathy diagnosis. Specific for dilated alcoholic cardiomyopathy is the reversible character of cardiomegaly, objectified through the reduction of the cardio-thoracic index in conditions of alcohol abstinence and adequate treatment of the heart failure.

[Some aspects regarding degenerative mitral valvular lesions encountered in medical practice]

In the last years, the degenerative valvular heart diseases have the tendency to equalize in frequency the rheumatismal valvular diseases. The maximum attention has been paid on the degenerative aortic stenosis as being a lesion with maximum frequency and a severe evolution. This study, given on the 18391 admissions in the period 1997-2001, is a retrospective analyse and it is concerned with the degenerative mitral valvular lesions. Of the 223 patients with degenerative valvular heart lesions, 139 patients (62.3%) had degenerative aortic stenosis and 96 patients (38.5%) were diagnosed with degenerative mitral valvular lesions from which 30 patients have had no association with aortic valvular lesions while 66 patients have had such an association. The pointed out types of mitral lesions were: the mitral insufficiency in 59 patients, the mitral annular calcification without hemodynamic disease in 19 patients, the mitral stenosis in 9 patients and the mitral disease in 9 patients, too. The women was affected nearly 1.7 times more frequent than the men, with a maximum average age greater with four years for women but with a low minimal average age at 60 years for women and 52 years for men. The detailed analyse of this 96 cases had shown the presence of a cholesterol value over 200 mg/dl in 50 patients (52%), the diabetic mellitus of type II in 12 patients (12.5%), an association with HTA in 42 patients (43.7%), the cardiac insufficiency in 68 patients (70.8%), a permanent atrial fibrillation in 24 patients (25%), the chronical myocardiac infarct in 19 patients (19.7%) and disorders in the transmission of stimuli in 8 patients (8.3%). The degenerative mitral valvular lesions had occurred more and more frequently realizing more complex features under the mitral insufficiency predominance. Its frequent association with the degenerative valvular lesions determines the evolutive and therapeutic particularities that are dominated by the high gravity prognostic.

[Myocardial remodeling]

Chamber remodeling and myocardial systolic dysfunction play an important role in the development of cardiac failure after myocardial infarction. The process is accompanied by qualitative and quantitative changes in the expression and reexpression of genes regulating cell growth and contractile function. The article tries to explain some of the mechanisms of the myocardial remodeling that permit the modifications and adaptation of the heart to normal and pathological conditions from a clinical point of view and, in the same time, from a molecular point of view.

[Analysis of some clinical aspects of degenerative valvular heart diseases in medical practice]

In a period of 5 years there were 18,391 admissions; out of them 1129 cases were diagnosed with valvular lesions: 223 (19.7%) were degenerative valvular heart disease, 608 (53.8%) had rheumatismal valvular lesions, 7 (0.6%) had congenital valvular lesions and 291 cases (25.7%) had valvular lesions of other etiologies. Out of the 223 cases with degenerative valvular lesions, 99 cases (44.4%) were men with an average age of 70.1 years old and 129 were women (55%) with an average age of 74.9 years old. The calcific aortic valve stenosis was encountered in 139 patients (62.3%), the aortic insufficiency was diagnosed in 19 patients (8.5%), the mitral insufficiency 49 patients (21.9%) and the mitral stenosis in 10 patients (4.4%) the other patients having either aortic or mitral valvular disease. The combination of an aortic stenosis with a mitral insufficiency was diagnosed in 46 cases (20.6%) from the 223. Only 14 patients were asymptomatic, most of them having heart failure (namely, 178 patients i.e. 78%) with or without angine pectoris or effort vertigo, or they had only effort angina, vertigo or effort sincope. Rhythm disorders happened in 59 patients (26.4%) while disorders in the transmission of the stimuli were diagnosed in 14 patients (5.2%). Two patients died due to cardiac causes.

CONCLUSION

Rheumatismal valve disease are nearly 2.5 times more frequent than degenerative valve disease and they became a practical reality, which is claimed by its continuously increasing frequency, by a variety of lesional aspects and by implications on the heart, and by it, presence in an age group were arteriosclerosis cumulates its risk factors.

[The implications of thromboembolism in chronic heart failure]

The goal of investigation was to determine whether long-term anticoagulant therapy influences the mortality rate in CHF. The method consisted in the calculation of the annual death rate of the patients with CHF class III-IV NYHA: group A (controls)--who did not receive anticoagulant or antiplatelet therapy; group B--treated with Acenocumarol or Aspirin. The results show in group A, which included 150 patients, during the 5-year interval under study 30 deaths, representing an annual death rate of 4%. In group B, which included 325 patients of which 75 treated with Acenocumarol and 250 patients with aspirin, 20 deaths were recorded during the same 5-year interval, representing an annual death rate of 1.2%. Thus, the mortality risk proved to be 70% lower in group B than in the control group. It came out that the main mechanism of death in CHF is thrombembolism and in this circumstance anticoagulant or antiplatelet therapy would be essential.

[Undesirable effects and interaction to angiotensin converting enzyme inhibitors therapy]

By their intervention upon the mechanisms regulating the vascular tone, renal plasma flow and direct actions of chemical structures, angiotensin-converting enzyme (ACE) inhibitors may determine undesirable effects. These effects formed the object of a 5-year retrospective study (1995-1999) carried out at the IIIrd Medical Clinic of Iasi. During this interval ACE inhibitors were administrated to 2178 patients with hypertensive and coronary disorders or heart failure of various causes. Different generations of ACE inhibitors were used, but captopril, enalapril and lysinopril were the most commonly administered. Undesirable effects were recorded in 161 patients (7.3%). The following side-effects, single or associated, were recorded: 38 patients (23.6%) had increasing blood pressure proportional with ACEI dose, 80 patients (49.7%) had decreasing blood pressure at low doses ACEI, 23 patients (14.4%) had kidney failure, 2 patients (1.2%) had both increasing blood pressure and kidney failure, 3 patients (1.9%) had both decreasing blood pressure and kidney failure, 6 patients (3.8%) had dry cough, one patient (0.6%) had kidney failure with decrease blood pressure and allergic dermatitis, 4 patients (2.4%) had allergic dermatitis, and 4 patients (2.4%) had headache, vertigo, paresthesia.

CONCLUSIONS

The treatment with ACE inhibitors has to be carefully initiated under strict clinical and biological monitoring, preferably in hospital setting. No drug associations that favor the undesirable effects of ACE inhibitors were reported.

[Nebivolol treatment in essential arterial hypertension]

Nebivolol is a lipophilic beta 1-blocker. It is devoid of intrinsic sympathomimetic or membrane stabilising activity but appears to have nitric oxide-mediated vasodilatory effects. Nebivolol 5 mg once daily is well tolerated in patients with hypertension. Adverse events are infrequent, transient and mild to moderate. Those reported most often include headache, fatigue, paraesthesias and dizziness. Several studies reported no signs of orthostatic hypotension with Nebivolol.

[Enzymatic markers in the alcoholic cardiomyopathy]

Alcoholic cardiomyopathy can ensue from heavy consumption of alcohol over a long period of time. The clinical features include dilatation of the left ventricle, poor myocardial contractility with reduced left ventricular ejection volume, raised tissue enzymes. In numerous experimental data has been observed increased generation of oxygen and ethanol free radicals, indicate that free radicals are implied in myocardial and hepatic damage. Ethanol administration also elicits hepatic disturbances in the availability of antioxidant defense. The resulting antioxidative stress leads to enhanced lipid peroxidation and can also affect other important cellular component.

[Hemorrhagic risk factors during beta-lactam antibiotics therapy]

Any type hemorrhagic manifestation may occur 12 hours to 5 weeks after the administration of beta-lactam antibiotics. The mechanisms of blood losses proved to be by: 1) immunologic thrombocytopenia (penicillins); 2) alteration of platelet functions (semisynthetic penicillins); 3) hypoprothrombinemia (cephalosporins). The risk factors for the occurrence of hemorrhage under beta-lactam antibiotics therapy are: concomitant administration of cytostatics for a neoplastic malignancy; b) acute or chronic renal failure; c) concomitant treatment for duodenal and gastric ulcer; d) malnutrition; e) dosage and duration of antibiotic administration. The frequency of bleeding under beta-lactams is not determined as yet. A severe case diagnosed at the IIIrd Medical Clinic of Iasi presenting spontaneous daily nasal bleedings that occurred 24 hours after the initiation of the treatment with cephalosporins (Kefurox) is presented. In this patient the risk factor was chronic renal failure.

[The cardiovascular significance of nitric oxide]

Nitric oxide (NO) synthesized from L-arginine is a ubiquitous intercellular chemical messenger involved in signal transduction in diverse mammalian cells. The isolation of molecular clones for NO synthases has permitted the characterization of several distinct enzyme isoforms. NO synthesized in vascular endothelial cells plays an important role in the control of vascular tonus and platelet aggregation, through the activation of guanylate-cyclase activity in target tissues mediated by NO. Nitric oxide which is produced by cytokine activated mononuclear cells plays an important role in inflammation and immunity as a cytotoxic effector molecule and as a transducer molecule in immune cells and in oxidative stress as a potential source of intracellular free radicals. An increase in reactive oxygen species can produce damage to lipids, proteins and DNA and induce necrosis or apoptosis. The implication of NO in different pathological processes, such as atherosclerosis, diabetes, ischaemia and reperfusion, or during inflammatory processes and the generation of free radicals contributing to the endothelial injury associated to these processes.

[The evolutionary characteristics of the hypereosinophilic syndrome]

The case here described is a young male aged 21 years who met all diagnostic criteria for HES: (1) persistent eosinophilia of over 1500/cubic millimeter (19.904-26.070/cubic millimeter) for longer than 6 month (12 month in our patient); (2) lack of evidence of other known causes of secondary hypereosinophilia (SH); (3) multiple organ involvement. The peculiar aspects found in our case are related to organ involvement: occurrence 2 months after HES onset of chronic myocardial infarction in four locations (apical, anteroseptal and posteroseptal, inferior, left ventricular) demonstrated by electrocardiographic and scintigraphic studies; early global cardiac insufficiency (6 months after the onset); acute renal failure (since HES onset) followed by chronic renal failure. The multiple and severe involvement of the nervous system (up to coma) were not a life threat. It is suggested that a possible explanation for the multiple organ involvement could be the chronic disseminated intravascular coagulation.

[Neurological manifestations on collagenoses]

Collagen diseases are precipitated by very different etiologic factors, but have a common pathogenic mechanism--autoimmune, which evolves chronically and progressively involving new territories. The initial and main pathologic lesions are vascular arterial ischemic (and, according to the prevalently involved territory, the type of disease results: PAN--medium-sized and small arterioles; scleroderma--small arterioles and capillaries), and the secondary ones are the result of ischemia with plurivisceral involvement. Neurological dysfunctions were detected in about 50% of collagen diseases diagnosed during a 25 year interval in the IIIrd Medical Clinic of Iaşi. The neurological manifestations were inaugural in 10% (in SLE) to 46.4% (in PAN) of the cases, the remainder occurring during the course of collagenosis, more commonly at 3-5 years and before death. Peripheral nervous system involvement (mainly polyneuritis) has prevailed, the central nervous system involvement being more rare and often fatal. Long-term corticosteroid therapy was followed by full or partial remission of peripheral nervous dysfunctions, but had transient effects or was ineffective on the central nervous ones.

[Therapeutic means and methods in recurrent pleurisy]

During a 10-year interval (1981-1991), at the IIIrd Medical Clinic of Iaşi 960 cases with pleural effusion, of which 768 (80%) non-recurrent and 192 (20%) recurrent, were diagnosed. The etiology in the latter cases was malignant (40%) and non-malignant (60%). Proper treatment methods for limiting or suppressing the recurrent pleurisies proved to be imperative. Thoracocenteses cause protein and electrolyte depletion which aggravate the general state and hasten the unfavourable evolution of the etiological affection. This is the reason why besides the general etiopathogenic treatment, a local pathogenic treatment (cytostatic, anti-inflammatory) and especially pleurodesis are compulsory. The intrapleural administration of cortisone is efficient in the case of recurrent autoimmune pleural effusions but is worthless in the malignant ones. In the latter situation, the intrapleural cytostatic treatment should be first attempted and, in case of failure, the development of pleural symphysis by external radiotherapy or injecting talc into the pleural space should be made. In the terminal stage of cardiac insufficiency or liver cirrhosis with recurrent pleural effusion, the pleurosymphysation is not indicated; a sever edematous-ascitic attack may occur or become aggravated by the pleural irritative process due to this method.

[The association of ventricular pre-excitation--acute myocardial infarct. The dysrhythmic outcomes]

The clinical manifestations of ventricular preexcitation, generally considered benign, may sometimes show the most unpredictable and severe evolution. Although ventricular tachyarrhythmias (those of ventricular aspect excepted) are extremely uncommon in ventricular preexcitation, cases of sudden death were nevertheless reported, their mechanism being the ventricular fibrillation. The authors have followed up the evolution of 12 patients (11 males, age between 38 and 72 years with a mean of 56 years) with acute myocardial infarction and coexistent ventricular preexcitation, previously depressed or newly detected, admitted during the last 10 years at the Coronary Unit of Iaşi. It is concluded that the association ventricular preexcitation--acute myocardial infarction represents a severe risk factor by sensibly increasing the arrhythmogenic potential.

[The effect of cardioversion in sinus rhythm on the systolic dynamics in atrial fibrillation and flutter]

In 60 cases of atrial fibrillation and flutter the systolic time intervals, haemodynamic ratios (PEj/PPE, PPE/PEj and PEj/TCIV) and ejection fraction before and after cardioversion in sinus rhythm were determined. The cardiac performance was markedly improved in all cases regardless the etiology and the degree of ventricular efficiency, pleading for the use of cardioversion anytime there is a chance to restore and maintain the sinus rhythm. The persistence of anticreased venous pressure, as well as the absence or late resumption of atrial mechanic activity usually indicate that arrhythmia soon recurs. In atrial fibrillation and atrial flutter, the inclusion in calculation only of those systoles preceded by R-R higher than 800 ms permits a better estimation of the degree of cardiac performance deterioration consecutive to the existing cardiopathy, the obtained data being very close to the postconversion values.

[The efficacy of electroversion in the treatment of tachyarrhythmia complications of the heart valves]

The results of electric cardioversion in the treatment of tachyarrhythmias in a series of 431 patients with valve diseases of the left heart admitted during the last 10 years are presented. Most patients presented atrial fibrillation (71.4%), the atrial flutter and paroxysmal tachycardia necessitating electric cardioversion in 24.5% and 4.1% of the cases, respectively. The restoration of sinusal rhythm was obtained in 90% of the cases, a single shock being delivered in most of them (74.5%). The patients' age, type of arrhythmia and the causal valvular heart disease did not influence the results, the essential factors of restoration and especially of maintaining the sinusal rhythm failure being the age of the valvular heart disease, the quality of atrial myocardium (which depends on the size of the enlargement and age of arrhythmia) and the association of a coronary or myocardial alcohol induced affection. The importance of estimating the resumption of atrial mechanic activity is underlined. The "regulation" embolism was rare (5 cases), while an embolism occurring during the preparation period raises the possibility of a possible coincidence between the embolic accident and the recurrence of atrial mechanical systole after electric cardioversion.

[The effect of captopril on the coronary circulation in a clinical and experimental study]

Taking into account the well-known angiotensin II-induced coronary constriction, in a first series of experiments the effects of captopril were studied upon the rabbit, guinea pig and rat coronary circulation during perfusion with oxygenated Krebs-Henseleit solution at 37 degrees C under constant pressure and variable flow according to the Langendorf technique. The inhibition of angiotensin I to angiotensin II conversion enzyme with captopril (5-500 microgr./ml) resulted in a coronary dose dependent dilation as a consequence of a reduction in the basal coronary tonus. Testing the coronary distensibility by using pressure and flow variations revealed a significantly increased distensibility when the conversion enzyme was specifically blocked with captopril. The anginal threshold of the atrial electrostimulation was increased after captopril (25-50 mg i.v.) in 15 out of 18 patients with coronary insufficiency by a mean value of 17%, white the systolic dynamics was significantly better. The obtained results bring new arguments in favour of the intrinsic renin-angiotensin system participation in maintaining the basal vascular tonus and of the increased coronary distensibility in the presence of captopril as an inhibitor of the local synthesis of the vasoconstrictor angiotensin II.

[The cardioprotective action of captopril during atrial electrostimulation]

The presence of R-A-A system components in all organs (heart included) has suggested a possible cardio-protective effect of the angiotensin conversion enzyme inhibitors as a result of coronary flow improvement. This effect would act irrespective of the well-known peripheral vascular effects: vasodilation, blood pressure decrease, pre- and postload reduction. By using the atrial pacing in the quantitative assessment of the anginal threshold and of the associated ECG alterations before and after the i.v. administration of 25 mg of captopril we could immediately evaluate the coronary reserves by estimating the efficiency of captopril in the patients with angina pectoris. The atrial pacing has been performed, by using the method suggested by Sowton, in 18 patients with typical angina. The increase of heart tolerance at exercise, the systolic dynamics improvement and the ejection fraction increase as well as the raising of the anginal threshold have been noticed in 15 of the patients. The blood pressure has evidenced no significant changes. After the administration of captopril, the ischemic ECG alterations have been less marked and their postpacing remains shorter. Our findings plead for a direct action of captopril on cardiac intrinsic R-A-A system in the normotensive patients suffering from angina pectoris.