Forearm and hand arteries’ aneurysms – a case report of bilateral true ulnar artery aneurysm in the hypothenar eminence and systematic review of the literature

Arterial aneurysms in the forearm, wrist and hand are relatively uncommon. Penetrating injuries, arterial traumas, infections and repetitive microtraumas represent the most frequent cause of these secondary aneurysms or pseudo-aneurysms, while true nontraumaticor infective peripheral aneurysms of the upper extremities are very rarely encountered. Over the last 20 years these have been reported only sporadically, both in adults and children. We describe a case of bilateral true idiopathic saccular artery aneurysms in the hypothenar eminence, treated with excision and arterial continuity restoration by primary end-to-end anastomosis on the left side and conservatively on the right. To our knowledge, no other similar case has been documented to date. Starting from this original case we conducted a systematic review of the literature via PubMed search on peripheral aneurysms of the forearm and hand arteries from 1933 to the present, including specifically true distal ulnar and radial artery aneurysms. Etiology, clinical characteristics and management of these rare pathological entities are extensively discussed.

Arterial entrapment syndrome in the cubital fossa: a rare cause of acute stress-related arterial thrombosis in a patient with brachial artery duplication

Arterial entrapment syndrome (AES) at elbow level is very rare and to our knowledge no case of AES by lacertus fibrosus in the cubital fossa in presence of brachial artery duplication has been described to date. We describe a rare case of acute arterial thrombosis of one of two brachial arteries highlighted in the cubital fossa which developed after strenuous right elbow flexor muscle activity and hyper-extensions presumably related to AES by lacertus fibrosus at elbow level. A 43-year-old right-handed woman, experienced paleness, coldness and numbness of the right hand, after 8 consecutive hours of gardening. As she worked, her ipsilateral flexor elbow muscles remained in prolonged and inappropriate tension. Clinical examination evidenced the absence of radial artery pulse in the wrist and mild hypothermia in the second and third finger. During surgical exploration two anastomosed brachial arteries were detected in the cubital fossa under the lacertus fibrosus. The lateral superficial brachial artery was occluded. Intraoperative arteriography evidenced brachial artery duplication at the third superior of the arm and normal vascular pattern at the forearm level. In cases of unexplained atypical intermittent upper extremity claudication or acute ischemic symptoms an AES should always be ruled out, particularly when symptoms are exacerbated by strenuous upper extremity activity or when upper limb muscular hypertrophy is evident. In these cases a thorough dynamic clinical and instrumental examination is mandatory to confirm a diagnosis of AES and to avoid possible future ischemic complications.

Anticoagulation Therapy for Postoperative Deep Vein Thrombosis Coupled with Pulmonary Embolism: A Potential Trigger for Delayed Popliteal Artery Injury Presentation after Total Knee Arthroplasty

Objectives:

A case of delayed popliteal artery injury (PA-INJ) onset after total knee arthroplasty (TKA) in a patient under postoperative anticoagulation therapy is reported. The role of anticoagulation both in late PA-INJ presentation and in PA-INJ management is discussed.

Report:

An obese 76-year-old woman was presented with a common femoral vein thrombosis coupled with pulmonary embolism five days after TKA. She was immediately placed under anticoagulation therapy. Four days later, during physiotherapy-supervised mobilization, she developed a calf haematoma and large retro-articular pseudoaneurysm. Angiography revealed a minor PA-INJ successively treated with a covered stent-graft.

Conclusions:

In cases of initially undetected and staunched TKA-related PA-INJs, postoperative anticoagulation therapy may act as a potential trigger for final arterial rupture during mobilization exercises, followed by acute bleeding; in these cases, endovascular management represents an excellent treatment option. Close clinical and instrumental monitoring is strongly recommended after TKA, in patients who imperatively require full-dose anticoagulation therapy.

[Neuroimaging and definition of transient ischemic attack]

AIM

Transient ischemic attack (TIA) has to be considered an "alarm bell" of a more or less severe organic or systemic vasculopathy. Positive findings at neuroimaging means tissue damage. The purpose of this retrospective study was to assess the role of neuroimaging in the management of patients presenting with TIA, and to consider the relative implications.

METHODS

In a consecutive series of 82 patients (53 males, 29 females, mean age: 65.9±13.1 years) admitted for TIA, it was possible to review the history and the clinical data of 66 patients, including ABCD2 score, laboratory including plasmatic D-dimer, and neuroimaging data including computed tomography (CT) and magnetic resonance imaging including diffusion-weighted with apparent diffusion coefficient measure (DWI-ADC) obtained at diagnosis and by a week later (16 by CT, and 50 by DWI-ADC). Thirty-three patients underwent DWI-ADC within 24 hours from symptoms onset. Statistical analysis has been performed by non-parametric tests (χ2 and Mann-Whitney), and logistic regression by a commercially available software.

RESULTS

CT and/or DWI-ADC showed signs of acute ischemic lesions in 23/66 (35%) patients. 12 out of the 35 patients with a 24-hour DWI-ADC follow-up were positive. Statistical analysis showed that positive neuroimaging was significantly associated only with familial history of cardiovascular diseases (P<0.012) and previous TIA/stroke (P<0.046).

CONCLUSION

In this patients series, at least 35% of patients with TIA had a positive neuroimaging, especially DWI-ADC. Positive neuroimaging seems an independent factor. Patients with TIA need an early assessment by neuroimaging including DWI-ADC, in order to obtain a correct classification and prognosis.

Complementary and Alternative Medicine (CAM) in paediatric rheumatology: a European perspective

OBJECTIVES

To analyse the use of complementary and alternative medicine (CAM) in children with rheumatic diseases, treated at a paediatric rheumatology centre in Italy.

METHODS

Parents of children with different kinds of chronic rheumatic diseases anonymously completed a questionnaire about their children's past or current use of CAM. Two groups of patients were analysed: Group A consisted of children who were still attending the centre; Group B consisted of children who had not attended the clinic for more than one year.

RESULTS

150 completed surveys were analysed: 22 paediatric patients (14.7%), 10/100 in group A and 12/50 in group B, used CAM to treat their diseases. The therapies used the most were homeopathy, herbal remedies, vitamins and minerals. We observed a significantly greater use of CAM among patients who had not attended the clinic for more than one year (24%) as compared to those who were regularly checked (10%) (p=0.02). Parents' use of CAM was significantly related to its use for their children (p=0.001). A poor outcome, probably related to the exclusive use of alternative treatments, was observed in three out of six patients who had completely stopped using traditional immunosuppressive drugs.

CONCLUSIONS

Physicians should be aware of the use of CAM particularly in patients who skip their regular check-ups. The use of CAM to treat childhood rheumatic conditions in Italy seems to be less frequent than in North America.

Localized superficial femoral vein thrombosis coupled with iatrogenic arteriovenous fistulas presenting as pulmonary emboli

INTRODUCTION

'Localized' femoral vein thrombosis (FVT) is a relatively rare condition usually associated with traumas, external compression or iatrogenic etiologies and the consequence can be pulmonary embolism.

REPORT

This is the case of a 46-year-old woman who presented with pulmonary emboli secondary to 'localized' superficial FVT, coupled with post-puncture arteriovenous fistulas (AVFs), two days after trans-femoral vein radio-frequency cardiac ablation. After placing a temporary IVC-filter, the AVFs were sutured directly while the residual FVT was treated conservatively.

DISCUSSION

Close local monitoring and adequate medical and surgical management are mandatory to avoid possible dangerous complications, also in apparently 'low-risk' iatrogenic AVFs.

Update on low molecular weight heparins at the beginning of third millennium. Focus on reviparin

BACKGROUND

This review provides an outline of the main pharmacological and clinical features of low molecular weight heparins (LMWHs) and a wider description of reviparin. The basic pharmacological properties of LMWHs are compared with those of unfractionated heparin, showing clear advantages of the former, mainly as for pharmacokinetic profile.

DESIGN

Consequently LMWHs are characterized by a more predictable behaviour. A key issue is the lack of "bioequivalence": LMWHs are in fact distinct chemical entities, with typical pharmacological and clinical profile for each agent. Therefore, they are not reciprocally interchangeable. The efficacy and safety of reviparin, a second generation LMWH, has been evaluated in many clinical trials as both thrombosis prevention and treatment. Reviparin use is documented in general and orthopaedic surgery. In patients undergoing abdominal surgery reviparin resulted more effective and better tolerated than unfractionated heparin (UFH). In total hip replacement patients, reviparin compared favourably with enoxaparin, showing the same efficacy but better safety. In patients who undergone total hip replacement, also the long-term, out of hospital prevention of deep vein thrombosis (DVT) has been proven.

CONCLUSIONS

The comparison with acenocoumarol demonstrated that reviparin was more effective in preventing DVT recurrences and far better tolerated than oral anticoagulant treatment. Reviparin was also effective and well tolerated in immobilised patients following leg injury with plaster casts or braces applications. Positive results were also obtained in the treatment of venous thromboembolism in well-designed studies on large patient populations. In this indication reviparin compared favourably with iv UFH. As for the use in cardiology patient, reviparin is at present the only approved LMWH for the prevention of acute thrombotic events in patients undergoing percutaneous transluminal coronary angioplasty.

Evaluation of the particle measurement programme (PMP) protocol to remove the vehicles' exhaust aerosol volatile phase

European regulation for Euro 5/6 light duty emissions introduced the measurement of non-volatile particles with diameter >23 nm. The volatile phase is removed by using a heated dilution stage (150 degrees C) and a heated tube (at 300-400 degrees C). We investigated experimentally the removal efficiency for volatile species of the specific protocol by conducting measurements with two Euro 3 diesel light duty vehicles, a Euro 2 moped, and a Euro III heavy duty vehicle with the system's heaters on and off. The particle number distributions were measured with a Scanning Mobility Particle Sizer (SMPS) and a Fast Mobility Particle Sizer (FMPS). An Aerosol Mass Spectrometer (AMS) was used to identify the non-refractory chemical composition of the particles. A Multi-Angle Absorption Photometer (MAAP) was used to measure the black carbon concentration. The results showed that the condensed material in the accumulation mode (defined here as particles in the diameter range of approximately 50-500 nm) was removed with an efficiency of 50-90%. The (volatile) nucleation mode was also completely evaporated or was decreased to sizes <23 nm; thus these particles wouldn't be counted from the particle counter, indicating the robustness of the protocol.

Early stratification of patients with chest pain and suspected acute coronary syndrome in the Emergency Department

AIM

The aim of this study was to investigate the accuracy of a critical pathway in the early stratification and management of patients with chest pain and suspected acute coronary syndrome (ACS) in the Emergency Department (ED).

METHODS

An observational study was performed enrolling all patients with non-traumatic chest pain and suspected ACS who presented during a one-year period in the ED, where a critical pathway with five-level risk stratification, based on risk factors, characteristics of pain and ECG, was implemented. Patients were prospectively evaluated for rates of death, unstable angina, myocardial infarction or revascularization procedure occurring during admission or in the 30 days following discharge from the ED. Receiver-Operating Characteristics (ROC) curve was used to measure the accuracy of the stratification method.

RESULTS

Overall, 1813 patients were enrolled: 475 patients (26.1%, 95% CI: 24.0-28.1 ) were admitted and 1338 (73.8%, 95% CI: 71.7-75.8) were discharged. Main outcomes occurred in 233 (49.9%, 95% CI: 47.5-52.2) of patients admitted and in 6 (0.4%, 95% CI: 0.06-0.7) of those discharged. The risk stratification system showed a good accuracy with an AUC-ROC curve of 0.90 (95% CI: 0.88-0.93). A total of 1541 (85%) patients were managed according to critical pathway. Adverse events were significantly fewer in patients discharged according to pathway criteria than in those who were not (0.27% vs. 1.37%, difference: 1.1% CI 95%: 0.06-2.1), without significant increase of inappropriate admissions.

CONCLUSION

A critical pathway, based on clinical and ECG features, is a safe and accurate tool to stratify and manage the patients with non-traumatic chest pain and suspected ACS in the ED.

Chemical characterization of emissions from modern two-stroke mopeds complying with legislative regulation in Europe (EURO-2)

In view of a new amendment to the European legislative regulation on emissions from two-stroke mopeds a study was carried out to comprehensively characterize exhaust gases of mopeds complying current EURO-2 emission standards. Three mopeds with different engine types (carburetor, direct injection, and electronic carburetion system ECS) where investigated by applying two different driving cycles, the legislative cycle ECE47 and the worldwide motorcycle test cycle WMTC. Thereby, particulate matter (PM), regulated compounds, carbonyls, volatile hydrocarbons (VOC), and particle-associated polyaromatic hydrocarbons (PAH) were analyzed and ozone formation potentials (OFP) as well as toxicity equivalents (TEQ) determined. The ECE47 emission factors for almost all species and moped types were much higher in the nonregulated, prior cold phase than in the hot phase, which is considered for legislation. Great differences for the mopeds could be observed for NO(x), VOC, and PM, whereas discrepancies between the driving cycles ECE47 and WMTC were smaller. In addition, a positive influence on exhaust composition caused by technical modifications of the ECS engine was determined. Results indicate that regulation of total hydrocarbons (THC) alone might not be sufficient to regulate PM, especially for direct injection engines. Moreover, recommendations for a revised future test protocol are demonstrated and discussed, whereby the cold phase and the hot phase are taken into account.