Ultrasound features of highly vascularized uterine myomas (uterine smooth muscle tumors) and correlation with histopathology.

OBJECTIVE: To correlate the ultrasound appearance of highly vascularized uterine myomas with their histopathological diagnosis. METHODS: This was a prospective observational study of patients with a preoperative ultrasound diagnosis of a highly vascularized uterine myoma (color score of 3 or 4, according to the Morphological Uterus Sonographic Assessment (MUSA) criteria), characterized by circumferential and intralesional vascular pattern, who underwent myomectomy or hysterectomy. For each patient, ultrasound characteristics were recorded at baseline, including the number of lesions, the size, echogenicity and border regularity of the lesion, presence of cystic areas and shadowing within the myoma, and visualization of the endometrium. Ultrasound features were correlated with the definitive histological diagnosis. Ultrasound features were then compared between malignant and benign lesions. RESULTS: We included 70 patients with highly vascularized uterine myomas on power/color Doppler. Their mean age was 46.5 ± 11.4 years and 13 (18.6%) were postmenopausal. At histological examination, 65 (92.9%) uterine myomas were benign lesions, comprising 32 typical leiomyomas, 29 leiomyoma variants and four adenomyomas. The remaining five (7.1%) uterine myomas were malignant masses, comprising two uterine sarcomas, one leiomyosarcoma, one neuroendocrine tumor and one uterine smooth muscle tumor of uncertain malignant potential (STUMP). The mean age of patients with a malignant lesion was significantly higher than the age of those with a benign lesion (64.8 ± 16.0 vs 42.4 ± 5.1; P < 0.001). Four out of five patients with a malignant lesion were over 45 years old. Ultrasound demonstrated cystic areas within the lesion in 10/32 (31.3%) typical leiomyomas, 16/29 (55.2%) leiomyoma variants, all four adenomyomas and in the cases of STUMP and leiomyosarcoma. Lesion borders were regular in 64/65 (98.5%) benign lesions and 2/5 (40%) malignant lesions (P < 0.05). No significant differences were observed between benign and malignant lesions with respect to echogenicity, presence of shadowing and size. The endometrium was visible in 55/65 women with benign lesions and in 2/5 with malignant lesions (P = 0.03). CONCLUSIONS: Our results showed that ultrasound features of uterine myomas, such as circumferential and intralesional vascularity, cystic areas and lesion borders, are important parameters for differential diagnosis, especially when combined with the patient's age. Such features could be useful to differentiate typical myomas from benign variants and malignant lesions in a preoperative setting and to select patients that may benefit from conservative management rather than surgery. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Remifentanil conscious sedation during regional anaesthesia for carotid endarterectomy: rationale and safety.

OBJECTIVES: to prospectively evaluate the safety and efficacy of remifentanil during regional anaesthesia for carotid endarterectomy. METHODS: twenty-eight consecutive patients underwent carotid endarterectomy with combined superficial and deep cervical plexus block supplemented with continuous intravenous 0.04 microg.kg(-1).min(-1)remifentanil infusion. Depth of sedation was monitored using the Observer's Assessment of Alertness/Sedation Scale (OAA/S). The degree of pain, discomfort and anxiety was self-assessed by the patients using a horizontal visual analogue scale. RESULTS: all patients experienced adequate comfort and analgesia. No local anaesthetic supplementation was necessary. No patient had a OAA/S score lower than 4 (with 5=awake/alert to 1=asleep). Respiratory depression did not occur. Selective shunting was required in four cases. No patient was converted to general anaesthesia. There were no permanent neurological deficits, cardiopulmonary complications or deaths. CONCLUSION: remifentanil as a supplement to regional anaesthesia for carotid endarterectomy, provides comfort and analgesia without hampering mental status evaluation.

The spatial relationships among cutaneous, muscle sensory and motoneuron axons during development of the chick hindlimb.

Previous studies have suggested that interactions with other axons are important in sensory axon pathfinding in the developing chick hindlimb. Yet the nature of these interactions remains unknown, in part because information about the spatial relationships among the different kinds of axons is lacking. To obtain this information, we combined retrograde axonal tracing with an immunofluorescent labelling approach that distinguishes between sensory and motoneuron axons. This allowed us to follow the trajectories of sensory axons having a known destination, while also identifying their neighbors. We found that as sensory and motoneuron axons meet in the spinal nerves and travel into the limb, sensory axons remain bundled together. The large bundles that are present proximally gradually split into smaller bundles as the axons course distally in the spinal nerves; more distally, some bundles join to again form large bundles. Younger, later-growing sensory axons appear to grow primarily along bundles of older sensory axons that grew out earlier. Starting from very proximal levels, axons projecting along an individual cutaneous nerve are found together in bundles that are situated in characteristic regions of each spinal nerve. Some of these bundles are initially interspersed with bundles of axons projecting along other nerves, thereby indicating that the initial position of a cutaneous axon in the spinal nerves does not strictly determine its subsequent trajectory. As they travel distally, bundles of axons projecting along one cutaneous nerve gradually join one another, becoming increasingly separated from axons having different destinations. In contrast, muscle sensory axons are situated adjacent to motoneuron axons innervating the same muscle for much of their course. This suggests that muscle sensory axons may be guided to the appropriate muscles by fasciculating along motoneuron axons. Taken together, the results show that sensory axons projecting along different nerves are different from one another and respond to cues in their environment to navigate through the spinal nerves and plexus. Thus, sensory neurons must be intrinsically specified with respect to their peripheral targets. Sensory axons appear to respond differentially to the axons they encounter, segregating from axons that project along different nerves and often growing with axons destined for the same nerve, suggesting that fasciculation may aid pathfinding.

In vitro studies of growth cone behavior support a role for fasciculation mediated by cell adhesion molecules in sensory axon guidance during development.

Axonal interactions, which are mediated by cell adhesion molecules (CAMs) as well as other types of membrane proteins, are important for sensory axon pathfinding in the developing chick hindlimb. We have previously shown that injection of antibodies that block the function of either G4/L1 or N-cadherin into the limb, starting when the first sensory axons reach the plexus, alters the segmental pattern of projections along cutaneous nerves. Specific removal of polysialic acid from NCAM using the enzyme endoneuraminidase N (Endo N) also resulted in significant changes in cutaneous projection patterns, while injection of antibodies against NCAM itself had no obvious effect (M. G. Honig and U. S. Rutishauser, 1996, Dev. Biol. 175, 325-337). To help understand the cellular basis for these findings, we developed a tissue culture system in which the axons from dorsal root ganglion explants grow within defined laminin lanes and examined whether the same treatments increased or decreased a growth cone's tendency to be closely associated with neighboring axons. After 2 days in culture, images of the cultures were recorded, antibodies or Endo N was added, and images of the same fields were recaptured an hour later. To quantify the results, growth cones located in defined regions of the laminin lanes were classified, before and after the perturbation, as "free" (i.e., growing primarily on the laminin substratum), "fasciculated" (i.e., growing tightly along other neurites), or "intermediate" (i.e., growing both on the laminin substratum and in contact with other neurites). We found that anti-G4/L1 and anti-N-cadherin, but not anti-NCAM, caused an increase in defasciculated growth cones, whereas Endo N resulted in an increase in fasciculated growth cones. These changes in fasciculation are consistent with the changes in cutaneous projections seen in our previous in ovo perturbations. The results from these tissue culture experiments thus provide strong support for the idea that one mechanism by which CAMs affect sensory axon pathfinding in vivo is by regulating the affinity of sensory growth cones for neighboring axons, which in turn can modulate the growth cone's ability to navigate through the surrounding environment.

External banding valvuloplasty of the superficial femoral vein in the treatment of recurrent varicose veins.

OBJECTIVES: The aim of this study is to evaluate the efficacy of reconstructive surgery of primary deep venous insufficiency in preventing recurrent varicose veins. DESIGN: Retrospective analysis of patients affected by recurrent varicose veins submitted to external banding valvuloplasty of the superficial femoral vein. SETTING: A division of vascular surgery in a hospital/scientific institute. MATERIALS: Nineteen limbs (19 patients) with recurrent varicose veins, severe chronic venous insufficiency and 3rd or 4th grade reflux in the superficial femoral vein and competence of the profunda femoris vein were selected for surgical reconstructive treatment after a complete diagnostic study by continuous wave Doppler duplex scanning and descending phlebography. INTERVENTIONS: External banding valvuloplasty of the superficial femoral vein was performed in all cases: A Dacron sleeve was used in nine patients and Venocuff in 10. RESULTS: In one case a deep venous thrombosis of the calf occurred in the first postoperative period; in three cases the correction of the deep reflux was incomplete and a recurrence of the varices was observed. After a mean follow-up of 50 months, abolition of reflux and relief of symptomatology were obtained in 15 cases (78%). CONCLUSIONS: Primary deep venous insufficiency, unknown at the time of the initial operation, may be the cause of recurrent varicose veins. External banding valvuloplasty of the superficial femoral vein may abolish the reflux and correct venous hypertension, preventing recurrences.

[The role of spinal cord electric stimulation in critical ischemia of the extremity]. / Il ruolo dell'elettrostimolazione midollare nell'ischemia critica d'arto.

The aim of this study is to evaluate, through a retrospective analysis of our experience, the effectiveness of spinal cord stimulation (SCS) in conservative treatment of critical limb ischaemia. During a 7-year period, at our Institution, SCS has been performed in 35 patients affected by severe lower limb ischaemia with angiographic multilevel distal lesions; femoro-distal bypass was not advisable or had failed due to poor outflow conditions. Basing upon clinical criteria (regression of rest pain, claudicatio and ischaemic lesions, limb salvage and need of amputation) the results of therapy were distinguished in "good,", "satisfactory" and "poor". Mean follow-up was 25 months (range 2-80). A good result has been achieved in 17 patients (48.5%) satisfactory in 11 (28.8%) and poor in 7 (20%), with a 80% limb salvage rate. No significative differences were observed in subgroups of patients with diabetes, hypertension or both. Appropriate management of critical limb ischaemia depends on a well-thought-out plan. Although femoro-distal vein bypass has been widely advocated as the treatment of choice, the good result of revascularization is related to adequate outflow conditions (adequate run-off). SCS has been reported to reduce ischaemic pain and improve ulcer healing and microcirculation in ischaemic limbs. Our experience and recent studies have provided strong evidence that SCS reduces tissue loss and improves limb salvage rate in inoperable patients. A prospective randomised study will be helpful in defining if SCS should represent an efficacious and alternative procedure to bypass in the treatment planning of critical leg ischaemia.

External banding valvuloplasty of the superficial femoral vein in the treatment of primary deep valvular incompetence.

Primary deep venous insufficiency (PDVI) represents an important cause of chronic venous insufficiency (CVI). The clinical picture is generally related to a congenital weakness of the vein wall at the level of the valvular ring which may dilate its diameter with consequent lengthening and prolapse of the valvular cusps. However, in an initial stage of PDVI the leaflets are normally formed and may undergo restorative surgery. In this condition an external banding valvuloplasty (EBV) with a Dacron sleeve around the incompetent valve may restore the competence. The authors report 54 cases of superficial femoral vein EBV performed over a period of 1986 to 1991. The patients were affected by signs of CVI and/or relapsing, complicated or atypical varices in which descending venography showed a grade II, III or IV primary deep reflux. In a mean follow-up of 38 months (4 to 63 months) deep reflux had disappeared in 41 patients (76%), had significantly decreased in 8 (14.8%) and was completely unmodified in 5 (9.2%). According to the experience of other authors, these results suggest the therapeutic validity of EBV in the initial stage of PDVI.

[Spinal cord electric stimulation vs. femoro-distal bypass in critical ischemia of the legs. Preliminary results in a randomized prospective study]. / Elettrostimolazione midollare vs bypass femoro-distale nell'ischemia critica degli arti inferiori. Risultati preliminari di uno studio prospettico randomizzato.

In the last few years the development of new and improved surgical procedures caused a more aggressive approach, by femoro-distal bypass, to the limb affected by critical ischaemia. A good surgical result is related to the crural vessel patency, the presence of an adequate autologous vein and the possibility to visualize inframalleolar and foot arteries by selective angiograms. Should all these conditions not be present, an outflow procedure might be at high risk for failure. On the other hand, several studies show that SCS relieves rest pain and improves trophic lesion healing although there is no evident increase in peripheral blood flow, but these studies refer to heterogeneous non-randomized patients. In order to evaluate the effectiveness of SCS compared to distal arterial reconstruction, we started this prospective and randomized study. In a period of 15 months, 12 patients affected by critical limb ischaemia at 4th stage of Fontaine with angiographic multilevel distal lesions were randomised for SCS (7 cases: group A) and distal bypass (5 cases: group B). The result of the therapy was judged as good or fair when either complete or evident pain regression and trophic lesion healing were obtained; otherwise the result was considered as poor. Actually the study is in progress, the follow-up is partial (3-12 months), the results are preliminary. In the patients of group A the results were good or fair in 5 cases (72%) and poor in 2 (28%). In the patients of group B the results were good or fair in 2 cases (40%) and poor in 3 (60%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Surgical reconstruction in deep venous insufficiency]. / La reconstruction chirurgicale dans l'insuffisance veineuse profonde.

Deep venous insufficiency is present clinically in post-phlebitis syndrome (PPS), above all at the stage of incompetence, after venous recanalisation, and in primary deep venous insufficiency (PDVI). Its different anatomical and pathological patterns lead to a varied management approach. Venous bypass procedures (using the techniques of Palma, Warren-Hushi, etc.) have been used in PPS at the obstructive stage but have now been virtually abandoned. In PPS at the stage of incompetence, after recanalisation, transposition of the incompetent vein to a competent vein has been suggested together with the grafting of a segment of valve-bearing vein. This is associated with many technical difficulties. In contrast, venous reconstruction surgery appears more promising in the case of PDVI. At the first stage, with a dilated vein and valve borders merely detached, it has been possible to obtain good results from external valvuloplasty by bandaging of the vein. The authors' experience at this stage involves a series of 54 operations with a follow-up of 4 to 63 months. At the late stage of PDVI, with frankly prolapsed valve borders, very useful results have been obtained form internal valvuloplasty, using various methods. Authors have recently been working on the artificial venous valve (Spiegowski, Taheri, Garcia-Rinaldi and ourselves) with uncertain results. We are currently studying a heterologous (metal and/or polymer) prosthetic device.

[Hepaticoportal arteriovenous fistula: a case report, discussion of physiopathological and clinical problems, and review of the published literature (author's transl)]. / A propos d'un cas de fistule artério-veineuse hépatico-portale. Problèmes de physiopathologie et clinique et revue de la littérature.

A patient developed an arteriovenous aneurysm between the gastroduodenal and middle colon arteries and the main mesentericoportal vein, following gastroduodenal resection. This case is described, and patients with arteriovenous fistulae in the portal region reported in the published literature (179 cases) are reviewed. Etiological, pathological, and clinical aspects in relation to surgical treatment and according to the type and location of the lesion, are also discussed. Emphasis is placed on a study of physiopathological problems, and the effects provoked by these fistulae on portal vein hemodynamics, arterial hemodynamic function, and on the general circulation are analyzed in greater detail.

[Percutaneous biopsy of the lungs: 136 biopsies in 80 patients (author's transl)]. / Agobiopsia percutanea del polmone: 136 biopsie in 80 pazienti.

The authors analyze their experience on 136 percutaneous biopsies of the lung performed on 80 patients during 3 years. Indications are given with particular reference to the technique, to the type of the needles used and the expedients adopted in order to reduce the complications. Patients to be subjected to biopsy should be correctly and carefully selected. To this purpose, the authors present a protocol used for the patients affected by localized or diffused, single or multiple pulmonary lesions. Percutaneous needle biopsy of the lung assumes a precise role in the numerous diagnostic studies on these patients. The technique is considered in some cases essential to the right management of the patient. In other cases, instead, it is considered superfluous or too risky for the presence of contraindications. As demonstrated by authors' experience, supported by others, the method has appeared easy to perform and apt to provide good diagnostic results.