Defining the Collateral Flow of Posterior Tibial Artery and Dorsalis Pedis Artery in Ischemic Foot Disease: Is It a Preventing Factor for Ischemia?

BACKGROUND: Critical limb ischemia, a worldwide prevalent morbidity cause, is mostly secondary to vascular insufficiency due to atherosclerosis. The disease presents with intermittent claudication, which can progress to critical limb ischemia requiring amputation. Research has emphasized that the quality or existence of the pedal arch have a direct effect on wound healing and, therefore, on limb salvage, through the mechanism of collateral vascularization to the ischemic regions. OBJECTIVES: This study aimed to determine the existence and, if present, grade of retrograde blood flow from plantar arch to dorsal foot artery (dorsalis pedis artery, DPA). The correlation between clinical symptoms and presence of collateral flow were also investigated. PATIENTS AND METHODS: Study group consisted of 34 cases, which included patient group (n = 17, all male, mean age: 68 years) and control group (n = 17, all male, mean age: 66 years). After physical examination and lower extremity Doppler examination, spectral morphology of DPA flow was recorded, before and during manual compression of posterior tibial artery (PTA), for a period of 5 seconds. At the end, findings of Doppler ultrasound, computed tomography angiography, magnetic resonance angiography and, physical examination finding and symptomatology were gathered and analyzed. RESULTS: In the patient group, 31 lower limb arteries, of total of 17 cases, were included. After compression maneuver, DPA in 11 cases (six right, five left) showed retrograde filling from plantar arch. This retrograde flow support was triphasic in three cases, biphasic in five cases, and monophasic in three cases. In other DPAs of these 20 limbs, PTA based retrograde collateral flow was not determined. In nine of these 20 limbs, with no or diminished retrograde filling, symptoms were worse than in other cases. Contrarily, only two of 11 limbs, with retrograde collaterals, have claudication during walking. CONCLUSION: In cases with critical atherosclerotic disease of anterior tibial artery, PTA-based biphasic or triphasic retrograde collateral flow prevents ischemia, whereas monophasic support or no retrograde flow remains incapable.

Perianal Fistula With and Without Abscess: Assessment of Fistula Activity Using Diffusion-Weighted Magnetic Resonance Imaging.

BACKGROUND: Magnetic resonance imaging (MRI) is highly accurate for the depiction of both the primary tract of fistula and abscesses, in patients with perianal disease. In addition, MRI can be used to evaluate the activity of fistulas, which is a significant factor for determining the therapeutic strategy. OBJECTIVES: This study aimed to determine the usefulness of diffusion-weighted (DW) MRI for assessing activity and visibility of perianal fistula. PATIENTS AND METHODS: Fifty-three patients with 56 perianal fistulas were included in the current retrospective study. The T2-weighted imaging (T2WI) and DWMRI were performed and apparent diffusion coefficient (ADC) values of fistulas were measured. Fistulas were classified into two groups: only perianal fistulas and fistulas accompanied by abscess. Fistulas were also classified into two groups, based on clinical findings: positive inflammatory activity (PIA) and negative inflammatory activity (NIA). RESULTS: Mean ADC value (mm(2)/s) of PIA group was significantly lower than that of NIA group, regarding lesions in patients with abscess-associated fistulas (1.371 × 10(-3) ± 0.168 × 10(-3) vs. 1.586 × 10(-3) ± 0.136 × 10(-3); P = 0.036). No statistically significant difference was found in mean ADC values between PIA and NIA groups, in patients with only perianal fistulas (P = 0.507). Perianal fistula visibility was greater with combined evaluation of T2WI and DWMRI than with T2WI, for two reviewers (P = 0.046 and P = 0.014). CONCLUSION: The DWMRI is a useful technique for evaluating activity of fistulas with abscess. Perianal fistula visibility is greater with combined T2WI and DWMRI than T2WI alone.

Circulating miR-21 and eNOS in subclinical atherosclerosis in patients with hypertension.

OBJECTIVES: The aim of this study is to evaluate the relationship of miR-21, nitric oxide (NOx) and endothelial nitric oxide synthase (eNOS) with subclinical atherosclerosis in carotid arteries by measuring carotid intima media thickness (CIMT) in patients with hypertension and healthy controls. DESIGN AND METHODS: A total of 28 hypertensive and 28 healthy controls were enrolled. MiR-21 expression was analyzed by quantitative reverse transcription-PCR and NOx, and eNOS levels were measured by ELISA assay. CIMT was evaluated by ultrasonography and CIMT ≥ 0.8 mm was accepted as increased CIMT (iCIMT). RESULTS: C-reactive protein (CRP) level, plasma miR-21 expression level and CIMT were found to be significantly higher in the hypertension group when compared to the control group (p = 0.009, p = 0.002 and p < 0.001, respectively). NOx and eNOS levels were significantly lower in the hypertension group compared to the control group (p < 0.001, both). MiR-21 level was positively correlated with the clinical systolic blood pressure, clinical diastolic blood pressure, CRP and CIMT. MiR-21 was also negatively correlated with NOx and eNOS. Eighteen patients with hypertension had iCIMT. MiR-21 and CRP levels were significantly higher (p < 0.001 and p = 0.001), whereas NOx and eNOS levels were significantly lower in patients with iCIMT (p < 0.001, both). CONCLUSION: The decreased levels of NOx and eNOS found in this study indicate the co-existence of endothelial dysfunction and hypertension once more. In the absence of microalbuminuria, the increased miR-21 expression in patients with iCIMT made us conclude that this miRNA might be involved in the early stages of atherosclerotic process in hypertensive patients.

Small bowel intussusception in a pregnant woman with Peutz-Jeghers Syndrome.

Intussusception is the most frequent complication of Peutz-Jeghers Syndrome (PJS), but usually seen in child age. It is a predictable, but infrequent complication in adults with PJS. However, there is no report about intussusception in pregnancy period secondary to Peutz-Jeghers (PJ) polyps in the literature. In this paper, we present a rare intussusception case in a pregnant woman with PJS, which was diagnosed with magnetic resonance imaging, and discuss this condition with a brief literature review.

Gastrointestinal Stromal Tumors with Unusual Localization: Report of Three Cases with a Brief Literature Review.

The most common tumors derived from the mesenchyme of the gastrointestinal system are stromal tumors. These tumors are typically seen in the stomach and small intestine and less frequently in the colon, rectum and esophagus and are very rarely located outside the gastrointestinal system. Cure is provided with complete surgical resection with resection borders free of tumor. Tumor size, mitotic index, localization, CD117 and CD34 negativity in immunohistochemical studies, mucosal ulceration and presence of necrosis help to predict recurrence of the illness and patient survival. In high-risk gastrointestinal stromal tumors (GISTs) there is an increased rate of recurrence and shortened survival despite complete surgical resection. Thus patients with a high-risk GIST should be given adjuvant therapy with imatinib mesylate. Sunitinib maleate is another FDA-approved agent only for cases who cannot tolerate imatinib or who are resistant to it. Herein we present three cases with GISTs in different locations of the gastrointestinal system with a review of the relevant literature.

Spontaneous intracranial hypotension syndrome in a patient with marfan syndrome and autosomal dominant polycystic kidney disease.

Intracranial hypotension is typically manifested by orthostatic headache. The most frequent underlying factor is cerebrospinal fluid leakage. It has been suggested that dural structural weakness in some connective tissue diseases may be responsible for dural tears and diverticula and consequently leakage. We present a case of spontaneous intracranial hypotension associated with Marfan syndrome and autosomal dominant polycystic kidney disease. The patient was treated successfully with epidural autologous blood patch. Dural involvements of these hereditary connective tissue diseases are also discussed.