Transcranial color Doppler in stroke-free adult patients with sickle cell disease.

The threshold velocity ≥200 cm/s at transcranial Doppler (TCD) evaluation is a useful cut-off for preventing the stroke (STOP trial) in pediatric patients with sickle cell disease (SCD), term including different types of sickle genotypes. Scanty data are available for adult SCD patients. We compared intracranial blood flow velocities between adult SCD patients and controls using transcranial color Doppler (TCCD), measuring the peak of systolic velocity (PSV) with the insonation angle correction and the pulsatility index (PI), an indicator of endothelial elasticity. Fifty-three adult SCD patients (aged >18 years) were enrolled (15 sickle cell anemia, 26 sickle cell thalassemia, and 12 HbS/HbC). None of the patients presented neurological signs. PSVs in middle cerebral artery (MCA) were higher in SCD patients than in controls (p = 0.001). In sickle cell anemia patients, PSVs were higher when compared to HbS/ßThal (p < 0.0060) and HbS/HbC patients (p < 0.0139). PI was within the lower range of normality in SCD patients compared to controls. Moreover, MCA-PSV was higher with lower Hb levels and higher HbS%; PI did not change with variation of Hb levels and HbS%.PSV and PI in SCD adult patients could be a relevant index to indicate the abnormal cerebral blood flow and to detect the sickle endothelial damage, in order to prevent cerebrovascular accidents.

Vertebral artery dissection in a child. Is "spontaneous" still an appropriate definition?

Though a rare cause of stroke in the general population, in almost one quarter of young patients affected by stroke cervical artery dissection (CAD) is the underlying cause. Among these cases "spontaneous" dissections, intended as non-traumatic, represent about 34% of posterior circulation arterial dissection in patients aged less than 18 years. We here describe the case of a seven-year-old boy who developed a spontaneous vertebral artery dissection (VAD) leading to occipito-mesial, thalamo-capsular and cerebellar infarction. Once a traumatic origin was excluded, clinical history and laboratory findings were further analysed: fever associated with tonsillitis during the previous week, raised inflammatory indices, a throat culture positive for beta haemolysing Streptococcus group A and high titres of streptococcal antibodies were found. This case suggests that patients with CAD referred as spontaneous deserve extensive analysis. Subjects presenting with a dissection and an underlying infection are likely to have a hyperinflammatory response (although further experience is needed). In these patients immediate start of antibiotic therapy, treatment with anti-inflammatory drugs and further a lifelong prophylaxis with antibiotics before any invasive procedure are strongly recommended.

Predictive factors for cholelithiasis complications.

BACKGROUND: Cholelithiasis is a benign disease that is very frequently encountered throughout the world. Its surgical mortality is usually minimal (0.1%), but the risk is considerably greater (2-10%) in patients developing complications particularly if they are elderly. The identification of possible predictive signs of complications is therefore crucial for the indication of preventive surgery. METHODS: The present study retrospectively examined 490 patients admitted to hospital because of complicated and uncomplicated cholelithiasis in order to establish the existence of previous (clinical or instrumental) symptoms that may be predictive of the course of the disease. The analysis of some variables (age, sex, pregnancy, diet, ethanol consumption, smoking, previous/concomitant diseases, and blood chemistry and instrumental test results) and the specific symptoms of cholelithiasis made it possible to identify two potential risk factors: an age of more than 60 years and the onset of biliary colic. RESULTS: The risk of developing complications is 3.2 times greater in patients aged more than 60 years than in those who are younger, and 3.3 times greater in symptomatic than in asymptomatic patients. Statistical analysis also revealed that the risk of complications is about ten times greater in patients with both risk factors than in those with neither. CONCLUSIONS: In conclusion, the indication for surgery must be considered absolute in symptomatic patients aged more than 60 years and relative to younger symptomatic patients.

Biochemical assay of collagen and elastin in the normal and varicose vein wall.

Alterations of the connective tissue in the varicose vein wall have been noted by several investigators; however, the cause of the vein dilatation has still not been established. The aim of this study was to find a biochemical explanation to the development of varices by evaluating sensitive biochemical markers of collagen and elastin in the varicose vein wall. 4-L-Hydroxyproline (HYP), as a marker of collagen content, and desmosine (DES) and isodesmosine (IDES), as markers of elastin, were measured in 47 macroscopically dilated and 32 nondilated segments of 20 varicose saphenous veins collected from 20 patients with varices. The same measurements were made in 24 fragments of normal saphenous veins collected from 14 patients in whom the vein was removed to be used for graft procedures. HYP (collagen) and DES and IDES (elastin) were determined with a colorimetric method and HPLC, respectively. ANOVA test was used to compare mean values (+/- SD). HYP and collagen content were similar in varicose and normal veins. There was a significant reduction of both DES and IDES in dilated segments of varicose veins (P < 0.05 vs normal veins and nondilated segments); the ratio of elastin to collagen was lower in varicose than normal veins (P < 0.05), and this reduction was most significant in the dilated segments (P < 0.01 vs normal veins). These results suggest that dilatation of the varicose vein wall may be related to some defect of elastin metabolism. Further studies on the metabolic activity of vein muscle cells are required.

[The trophic venous ulcer. The physiopathological, microbiological and pharmacological aspects]. / L'ulcera trofica venosa. Aspetti fisiopatologici, microbiologici e farmacologici.

The ulcus cruris is an ulcerative lesions caused by chronic venous stasis and chronic venous hypertension. Every pathologic obstacle to venous return can cause ulcus cruris. Ulcus could be brought back to 3 situations: postphlebitic syndrome, chronic venous insufficiency and primitive varicosities. The common denominator is always the increase in venous pressure, the appearance of reflux and venous stasis. Venous ulcers are possibly characterized by tissue degeneration and by bacterial superinfection. A particular bacterial flora is found in these injuries, it is qualitatively different from that of healthy skin. The therapy of ulcus cruris cannot leave out by its etiopathogenesis: the first treatment always consists in the stasis suppression to arrive quickly to a complete cicatricial would repair. In it three moments are recognizable: ulcus abstersion, disinfection and cicatrization. The venous ulcer is not cured when it is closed, but when it has no recurrency: the cicatrization is obtainable treating the principal causes, eliminating the venous stasis and anticipating the relapses.

A new device for the detection of sponges and other foreign objects left accidentally in the operative field.

A new cost-effective device for the detection of sponges and other instruments left accidentally in the surgical field is presented. This device has 100 per cent sensitivity rate in the initial tests. It is extremely simple and rapid and does not require the use of radiation or other harmful techniques.

[Venous Doppler velocimetry: ten years of development of a method]. / La velocimetria Doppler venosa: dieci anni di evoluzione di un metodo.

Doppler velocimetry enables three haemodynamic parameters that are extremely useful for the study of venous diseases to be evaluated: blood flow direction, the morphology of the velocity wave and venous pressure. These three parameters are used in association depending on the particular requirements of the diagnostic problem. In the case of suspected deep venous thrombosis, study of the morphology of the velocity wave and clinostatism pressure give good diagnostic possibilities for the iliaco-femoral axis but poor for the leg trunks. In post-thrombotic syndrome, Doppler velocimetry is not so useful because the patient has to remain immobile during the examination while this specific pathology features insufficiency of the muscular pump during walking. In varicose disease, the investigation offers a very high diagnostic capability by evidencing the site and extent of valvular incontinence in the saphena and perforating vessels. The only limitation is the presence of numerous incontinent perforating vessels, but this is infrequent. In this pathology, Doppler v. has almost completely supplanted phlebography because it responds to the needs of modern medicine to replace invasive diagnostic investigations with non-invasive techniques that are equally effective. Finally, two other fields of application are very important for this investigation: the study of a patient with varices prior to saphenic stripping and prior to sclerotherapy. Definition of the origin and course of the reflux ways makes an optimal result possible, even allowing for the evolution of varicosity.

The effects of a hydrocolloid dressing on bacterial growth and the healing process of leg ulcers.

Thirty patients with lower extremity ulcers of different aetiologies, although mainly of venous origin, were treated with an occlusive hydrocolloid dressing twice a week for a maximum period of 12 weeks. No antibacterial chemotherapy was utilized. A culture was taken of the exudate of the ulcer before commencement of treatment and weekly or bi-weekly thereafter. The results showed a mixed flora with prevalence of Staphylococcus aureus. The average duration of the treatment period was 67 +/- 11 days with a total of 26 patients being healed by the end of this period. The average interval between dressing changes was 4.1 days. Subsequent bacterial cultures showed a persistence of the original flora, but there was no correlation between the type of flora present and clinical evidence of infection or between the type of flora present and the rate of healing of the ulcer. Clinical evaluation of the results obtained with the hydrocolloid dressing was favourable in respect to reduced risk of contamination of the ulcer, lower pain perception and less trauma to the granulation tissue during dressing changes.

Doppler examination in varicocele. A standard method of evaluation.

Doppler sonography is considered a reliable method for detecting reflux due to venous valvular incompetence, which occurs in varicocele. It is, however, a matter of debate whether the characteristics of this reflux can be correlated quantitatively in a clinical setting. In this study, a two-step method was utilized to identify reflux in basal conditions with the patient standing and breathing spontaneously and to determine the time of centrifugal secondary venous reflux of the distal spermatic cord during the squeezing and relaxing maneuver. This method is closely related to that used by the vascular surgeon to detect valvular incontinence of the saphenous vein. Since Doppler sonography is much more reproducible than Valsalva's maneuver, it is therefore much more reliable. In a 12-month period, 625 patients with pathologic findings in at least two spermiograms were studied. Thirty percent showed constant basal reflux not influenced by respiratory exhilation. The squeezing and relaxing maneuver induced secondary reflux longer than 1.6 seconds in 17%, between 0.8 and 1.6 seconds in 17% and less than 0.8 seconds in 36% of the patients. The higher sensitivity and specificity of Doppler examination compared with thermography and angiography, as well as its low cost and noninvasiveness, make this the procedure of choice in the diagnosis of venous reflux in varicocele.

Penile arterial Doppler evaluation in basal condition and after intracavernous injection of papaverine.

In diagnostic screening, 73 impotent patients were submitted to a Doppler study of the deep penile arteries under basal conditions and after oral nitroglycerin (Basal-DOPPLER) and after intracavernosal injection of 30 mg of papaverine (ICIP-DOPPLER), as well as other tests. The results of the Basal-DOPPLER and the erectile response to intracavernosal administration of 30 mg papaverine (ICIP-30), indicative of the condition of the deep penile arteries, were in total agreement for 33 cases, partial agreement for 29 cases and totally in disagreement for 11 cases. The agreement between the results of the ICIP-DOPPLER and the ICIP-30 was total for 40 cases, partial for 24 and totally lacking for 9. In many of the cases for whom the response to ICIP-30 was less than would have been expected from the ICIP-DOPPLER, abnormal venous outflow was later shown. Our data support the hypothesis that papaverine acts on the venous component of erection. The ICIP-DOPPLER was found to be apparently more reliable than the Basal-DOPPLER for evaluating the arterial component of erection, but Basal-DOPPLER is still the basic screening test before any such invasive test as the ICIP are used, since these latter are not always accepted immediately by the patients.

[Microvalves in microvenules]. / Les microvalvules dans les microveinules.

A long-lasting histological study on muscle and cutaneous-subcutaneous biopsies allowed certain observations of microvalves in venules with a diameter ranging from 80 to 200 micron. Venular leaflets originate from the vein as extroflection of the intima, made by a single layer of endothelial cells. In the patient affected by severe chronic venous insufficiency the valvular leaflets appear thickened while the wall of the venule presents sclero-hyalinotic alterations. The presence of microvalves in venules suggests a role of their incontinence in the venous insufficiency. Considering that the venular leaflets are made just by endothelial cells, a primary pathogenetic role has to be achieved to the endotheliopathy in the genesis of venous insufficiency.