Quantitative Optical Coherence Tomography Angiography Detects Retinal Perfusion Changes in Carotid Artery Stenosis

Background

Carotid artery stenosis (CAS) is a multifaceted disease characterized by possible ocular involvement. Treatment with carotid endarterectomy helps to restore cerebral perfusion, which may prevent ocular and cerebral complications. The main aim was to assess retinal and choroidal vascular perfusion changes before and after endarterectomy in patients affected by CAS.

Methods

The design of the study was prospective and observational, including patients affected by CAS and healthy controls. The follow-up was 3 months. We performed quantitative optical coherence tomography (OCT) angiography (OCTA) analyses of retinal perfusion changes, before and after endarterectomy. The main outcome measures were the quantitative changes of choroidal thickness (CT), retinal nerve fiber layer (RNFL), and ganglion cell layer (GCL); vessel density (VD); and vessel tortuosity (VT) OCTA metrics were also measured.

Results

Sixty eyes of 30 patients affected by CAS and 30 eyes of 30 controls were included. We separately considered the ipsilateral eyes to CAS, the contralateral eyes to CAS, and the healthy eyes. Visual symptoms were absent in all the patients. RNFL and GCL resulted similar between patients and controls (p > 0.05). CT was significantly thinner in ipsilateral eyes than controls (p < 0.01), and it resulted unchanged after surgery (p > 0.05). VD resulted significantly altered only in some plexa of the ipsilateral eyes (p < 0.01), whereas VT disclosed decreased values of the entire retinal vascular network, both in ipsilateral and contralateral eyes (p < 0.05). Endarterectomy was followed by statistically significant improvement of retinal perfusion (p < 0.05).

Conclusion

Optical coherence tomography angiography can noninvasively detect postendarterectomy retinal perfusion improvements in CAS patients with baseline diabetes and hypertension as a systemic risk factor.

Doppler Ultrasound Monitoring of Echogenicity in Asymptomatic Subcritical Carotid Stenosis and Assessment of Response to Oral Supplementation of Vitamin K2 (PLAK2 Randomized Controlled Trial)

BACKGROUND

Plaque composition may predict the evolution of carotid artery stenosis rather than its sole extent. The grey scale median (GSM) value is a reproducible and standardized value to report plaque echogenicity as an indirect measure of its composition. We monitored plaque composition in asymptomatic subcritical carotid stenosis and evaluated the effect of an oral modulating calcification factor (vitamin K2).

METHODS

Carotid plaque composition was assessed by GSM value. Monitoring the effects of standard therapy (acetylsalicylic acid and low-medium dosage statin) (acetylsalicylic acid (ASA) arm) or standard therapy plus vitamins K2 oral supplementation (ASA + K2 arm) over a 12 months period was conducted using an ultrasound scan in a prospective, open-label, randomized controlled trial (PLAK2).

RESULTS

Sixty patients on low-medium dosage statin therapy were enrolled and randomized (30 per arm) to either ASA + K2 or ASA alone. Thirty-seven patients (61.6%) showed at 12 months a stable plaque with a mean increase in the GSM value in respect to the baseline of 2.6% with no differences between the two study arms (p = 0.66). Fifteen patients (25%) showed an 8% GSM value reduction respect the baseline with no differences between the two study arms (p = 0.99). At multivariable analysis, the adjusted mean (95% confidence interval) GSM change per month from baseline was greater in the ASA + K2 arm (-0.55 points, p = 0.048) compared to ASA alone (-0.18 points, p = 0.529).

CONCLUSIONS

Carotid plaque composition monitoring through GSM value represents a laborious procedure. Although its use may not be applied to everyday practice, a specific application consists in evaluating the effect of pharmacological therapy on plaque composition. This 12 months randomized trial showed that the majority of subcritical asymptomatic carotid plaque on treatment with low-medium dosage statin presented a stable or increased echogenicity. Although vitamin K2 beyond standard therapy did not determine a significant change in plaque composition, for those who presented with GSM reduction it did enhance a GSM monthly decline.

A chemogenomic approach to identify personalized therapy for patients with relapse or refractory acute myeloid leukemia: results of a prospective feasibility study

Targeted next-generation sequencing (tNGS) and ex vivo drug sensitivity/resistance profiling (DSRP) have laid foundations defining the functional genomic landscape of acute myeloid leukemia (AML) and premises of personalized medicine to guide treatment options for patients with aggressive and/or chemorefractory hematological malignancies. Here, we have assessed the feasibility of a tailored treatment strategy (TTS) guided by systematic parallel ex vivo DSRP and tNGS for patients with relapsed/refractory AML (number NCT02619071). A TTS issued by an institutional personalized committee could be achieved for 47/55 included patients (85%), 5 based on tNGS only, 6 on DSRP only, while 36 could be proposed on the basis of both, yielding more options and a better rationale. The TSS was available in <21 days for 28 patients (58.3%). On average, 3 to 4 potentially active drugs were selected per patient with only five patient samples being resistant to the entire drug panel. Seventeen patients received a TTS-guided treatment, resulting in four complete remissions, one partial remission, and five decreased peripheral blast counts. Our results show that chemogenomic combining tNGS with DSRP to determine a TTS is a promising approach to propose patient-specific treatment options within 21 days.

IL-1β/MMP9 activation in primary human vascular smooth muscle-like cells: Exploring the role of TNFα and P2X7

BACKGROUND

Vascular smooth muscle cells exhibit phenotypic plasticity in response to microenvironmental stimuli and contribute to vascular remodelling through mechanisms only partially understood. In atherosclerosis, P2X-purinoceptor7 (P2X7) has been related to interleukin-1β (IL-1β) and metalloproteinase 9 (MMP9). The hypoxia-inducible factor-1alpha (HIF1α) was associated to remodelling. Here the activation of IL-1β and MMP9 was studied in relationship to P2X7 and HIF1α in cells exploited from human carotid plaque and internal mammary artery.

METHODS AND RESULTS

Migrating cells expressed HIF1α-regulated canopy FGF-signalling regulator 2 and CD117, and led to primary cells with SMC-like phenotype (VSMC), P2X7⁺. We investigated in VSMC the effects of hypoxia, of treatment with tumour necrosis factor-α (TNFα) and/or with P2X7 antagonist, A740003. Quantitative RT-PCR showed that hypoxia unaffected IL-1β and down-regulated MMP9 mRNAs, without activating HIF1α. TNFα increased IL-1β mRNA via NLR Family Pyrin Domain-Containing 3, with production of proIL-1β but no rise of mature IL-1β. Zymography demonstrated that A740003 triggered MMP9 secretion from VSMC. Combination of A740003 with TNFα abrogated this effect. Combination was ineffective on IL-1β activation elicited by TNFα, but down-regulated HIF1α mRNA. A740003 induced the intracellular P2X7 aggregation and differently perturbed lysosome and mitochondria network compared to TNFα.

CONCLUSIONS

Cells migration from human arteries leads to partially differentiated VSMC analogous to neointimal cells within atherosclerotic lesions. Down-regulated HIF1α in stimulated VSMC translates in resilience in atherosclerotic lesions. P2X7-independent partial activation of IL-1β elicited by TNFα underlines complexity of the cytokine secretion. Data also supported P2X7 as modulator of MMP9 secretion, important for atherosclerosis progression.

P2X7 receptor antagonism modulates IL-1β and MMP9 in human atherosclerotic vessels

In atherosclerosis, matrix metallopeptidases (MMPs) contribute to plaque rupture through weakening of the fibrous cap. Pleiotropic P2X purinoceptor 7 (P2X7), expressed in the carotid plaque (PL), is involved in interleukin 1 beta (IL-1β) release that may influence MMP9 generation, thus their possible modulation through acting on P2X7 was investigated. P2X7-related machinery was characterized and the effects of P2X7 antagonists (A740003, KN62) and MMPs inhibitors (Batimastat, Ro28-2653) were studied in ex-vivo tissue cultures of human PL’s vs. non-atherosclerotic internal mammary artery (IMA) by using molecular biology, immune-biochemical and microscopy methodologies. We highlighted atherosclerosis-related differences between PLs and IMAs molecular patterns, and their responsivity to P2X7 antagonism. High IL-1β tissue content was associated with PLs morphology and instability/vulnerability. We demonstrated that A740003, but not KN62, decreased IL-1β and MMP9 independently from NLR family pyrin domain containing 3, but in relationship with patient’s smoking status. Acting downstream P2X7 by MMPs inhibitors, diminished IL-1β mRNA without transcriptional effect at MMP9, possibly because the assumption of statin by patients. These data firstly demonstrated A740003 suitability as a specific tool to decrease inflammatory status in human vessels and might support the design of studies applying P2X7 antagonists for the local targeting and tailored therapy of atherosclerosis.

Endovascular Treatment of Visceral Artery Aneurysms and Pseudoaneurysms in 100 Patients: Covered Stenting vs Transcatheter Embolization

Purpose: To retrospectively report a large single-center experience of visceral artery aneurysms (VAAs) and pseudoaneurysms (VAPAs) treated with covered stenting (CS) as the first therapeutic option vs transcatheter embolization (TE). Methods: One hundred patients (mean age 59±14 years; 58 men) underwent 59 elective and 41 emergent endovascular procedures to treat 51 VAAs and 49 VAPAs. Seventy patients had TE and 30 received CS (27 Viabahn and 3 coronary stent grafts). Both TE and CS were performed in 10 cases. Results: Technical success was 96% (97% CS, 96% TE), and 30-day clinical success was 83% (87% CS, 81.4% TE). Four major complications occurred; 30-day mortality was 7%, mainly due to septic shock following pancreatic surgery. The midterm follow-up was 20.8 months in the total population and 32.8 months in the CS group. More than 6 months after CS all aneurysms remained excluded; stent patency was achieved in 88%. Twelve CS patients with >3 years’ follow-up had maintained stent patency. Conclusion: In endovascular treatment of visceral aneurysms, covered stenting was feasible in 30%. CS showed a slightly better efficacy than TE and good midterm patency. The Viabahn covered stent seems to be suitable for endovascular repair of tortuous visceral arteries affected by true or false aneurysms.

Nectin-4: a new prognostic biomarker for efficient therapeutic targeting of primary and metastatic triple-negative breast cancer

Background

Triple-negative breast cancers (TNBCs) are associated with a poor prognosis. In contrast to other molecular subtypes, they have no identified specific target and chemotherapy remains the only available systemic treatment. The adhesion molecule nectin-4 represents a new potential therapeutic target in different cancer models. Here, we have tested the prognostic value of nectin-4 expression and assessed the therapeutic efficiency of an anti-nectin 4 antibody drug conjugate (ADC) on localised and metastatic TNBC in vitro and in vivo.

Materials and methods

We analysed nectin-4/PVRL4 mRNA expression in 5673 invasive breast cancers and searched for correlations with clinicopathological features including metastasis-free survival (MFS). Immunohistochemistry was carried out in 61 TNBCs and in samples of primary TNBC Patient-Derived Xenografts (PDXs). An anti-nectin-4 antibody eligible for ADC was produced and tested in vitro and in vivo in localised and metastatic TNBC PDXs.

Results

High nectin-4/PVRL4 mRNA expression was associated with poor-prognosis features including the TN and basal subtypes. High PVRL4 mRNA expression showed independent negative prognostic value for MFS in multivariate analysis in TNBCs. Nectin-4 protein expression was not detected in adult healthy tissues including mammary tissue. Membranous protein expression was found in 62% of TNBCs, with strong correlation with mRNA expression. We developed an ADC (N41mab-vcMMAE) comprising a human anti-nectin-4 monoclonal antibody conjugated to monomethyl auristatin-E (MMAE). In vitro, this ADC bound to nectin-4 with high affinity and specificity and induced its internalisation as well as dose-dependent cytotoxicity on nectin-4-expressing breast cancer cell lines. In vivo, this ADC induced rapid, complete and durable responses on nectin-4-positive xenograft TNBC samples including primary tumours, metastatic lesions, and local relapses; efficiency was dependent on both the dose and the nectin-4 tumour expression level.

Conclusion

Nectin-4 is both a new promising prognostic biomarker and specific therapeutic target for ADC in the very limited armamentarium against TNBC.

Continuity of attachment in children with disruptive behavior disorders and in their parents: A pilot study

Introduction

The quality of adult–infant attachment plays an essential role in influencing the children's well-being (Groh et al., 2012). Disruptive Behavior Disorders (DBD) has been found as particularly influenced by the presence of unavailability in the parental caregiving. It is widely attested that parents’ attachment states of mind predict the attachment patterns of their children. Nonetheless, the investigation of the attachment organization during the middle childhood shows inconsistent data. Moreover, a paucity of studies focused on the role of father's attachment in this period still remains.

Objectives

This pilot study investigates the attachment patterns of children with DBD and those of their parents.

Aims

The aims are to verify the presence of: (1) an over-representation of Disorganized attachment in these children; (2) an over-representation of Irresolution with respect to abuse or loss in one or both their parents.

Methods

The sample consists of 33 subjects: n = 11 children with DBD and n = 22 parents. The children completed the Child Attachment Interview (Shmueli-Goetz et al., 2000) and the parents completed the Adult Attachment Interview (George et al., 1985).

Results

Findings showed: (1) a significant presence of Disorganized attachment with respect to both parents in the children; (2) an over-representation of Insecure states of mind in their parents; (3) a more significant presence of Disorganization in the fathers than in the mothers.

Conclusion

This focus on the topic of intergenerational transmission of attachment in a specific clinical sample enriches the research, underlining the more pronounced role of fathers’ attachment configuration.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Disruptive behavior disorders and somatic symptoms disorders: Which strategies of emotion regulation children and their parent's use?

Introduction

Emotion regulation (ER) is defined as the processes through which emotional awareness and experience are monitored, evaluated, maintained, and modified (Thompson, 1994). Difficulties with these processes have been proposed to increase risk for psychopathology. Disruptive behavior disorders (DBD) and somatic symptoms disorders (SSD) are characterized by an inability to express and modulate emotional states. Research aims to understand how ER influences mental health.

Objectives

We focus on two strategy of ER: Cognitive Reappraisal, involves changing the way one thinks about a situation in order to change its emotional impact; Expressive Suppression involves suppressing or hiding external expressions of emotion from others (John and Gross, 2004)

Aims

We assess ER in order to examine the relation with SSD and DBD in childhood and with their parents.

Methods

The sample consists of 188 subjects divided in four groups: n = 41 children with DBD (M = 10.78 years, SD = 2.11); n = 50 parents (36 mothers and 14 fathers) of children with DBD; n = 44 children with SSD (M = 11.98 years, SD = 2.04); n = 53 parents (40 mothers and 11 fathers) of children with SSD. Were administered the ERQ (Balzarotti et al., 2010) for parents and ERQ-CA (Gullone and Taffe, 2012) for children.

Results

DBD children reported higher levels of Suppression than SSD subjects; high levels of Suppression were reported in mother SSD and in father DBD.

Conclusion

This study extended previous research in childhood, including both mothers and fathers. The findings contribute to a greater understanding of the development of ER, which has important implications for psychological wellbeing.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

A robust and rapid xenograft model to assess efficacy of chemotherapeutic agents for human acute myeloid leukemia

Relevant preclinical mouse models are crucial to screen new therapeutic agents for acute myeloid leukemia (AML). Current in vivo models based on the use of patient samples are not easy to establish and manipulate in the laboratory. Our objective was to develop robust xenograft models of human AML using well-characterized cell lines as a more accessible and faster alternative to those incorporating the use of patient-derived AML cells. Five widely used AML cell lines representing various AML subtypes were transplanted and expanded into highly immunodeficient non-obese diabetic/LtSz-severe combined immunodeficiency IL2Rγ_c^null mice (for example, cell line-derived xenografts). We show here that bone marrow sublethal conditioning with busulfan or irradiation has equal efficiency for the xenotransplantation of AML cell lines. Although higher number of injected AML cells did not change tumor engraftment in bone marrow and spleen, it significantly reduced the overall survival in mice for all tested AML cell lines. On the basis of AML cell characteristics, these models also exhibited a broad range of overall mouse survival, engraftment, tissue infiltration and aggressiveness. Thus, we have established a robust, rapid and straightforward in vivo model based on engraftment behavior of AML cell lines, all vital prerequisites for testing new therapeutic agents in preclinical studies.

Anti-leukemia activity of chaetocin via death receptor-dependent apoptosis and dual modulation of the histone methyl-transferase SUV39H1

Epigenetic deregulation is involved in acute myeloid leukemia (AML) pathogenesis and epigenetic targeting drugs are in clinical trial. Since the first results with histone-deacetylase inhibitors in AML are controversial, novel single and combined treatments need to be explored. It is tempting to combine chromatin-targeting drugs. SUV39H1, the main methyl-transferase for lysine 9 tri-methylation on histone H3, interacts with oncogenes involved in AML and acts as a transcriptional repressor for hematopoietic differentiation and immortalization. We report here that pharmacological inhibition of SUV39H1 by chaetocin induces apoptosis in leukemia cell lines in vitro and primary AML cells ex vivo, and that it interferes with leukemia growth in vivo. Chaetocin treatment upregulates reactive oxygen species (ROS) production as well as the transcription of death-receptor-related genes, in a ROS-dependent manner, leading to death receptor-dependent apoptosis. In addition to its direct inhibition by chaetocin, SUV39H1 is indirectly modulated by chaetocin-induced ROS. Accordingly, chaetocin potentiates other anti-AML drugs, in a ROS-dependent manner. The decryption of a dual mechanism of action against AML involving both direct and indirect SUV39H1 modulation represents an innovative read-out for the anticancer activity of chaetocin and for its synergy with other anti-AML drugs, suggesting new therapeutic combination strategies in AML.

Endovascular abdominal aortic aneurysm repair in a patient with severe hemophilia B

PURPOSE

To report a case of endovascular aneurysm repair (EVAR) in a patient with severe hemophilia B.

CASE REPORT

A 63-year-old man with severe hemophilia B was referred for the treatment of a symptomatic infrarenal aortic aneurysm that had enlarged from 3.1 to 4.2 cm in diameter in the last 6 months. The patient was successfully treated with EVAR, associated with perioperative administration of titrated doses of high-purity factor IX concentrate. There were no perioperative complications, but a small type II endoleak was found on the initial postoperative computed tomographic scan; on the 6 month scan, the endoleak had not changed, and it is under intensive surveillance.

CONCLUSION

This case demonstrates that endovascular abdominal aortic repair is safe and feasible in severe hemophilic patients managed perioperatively with deficient coagulant protein replacement.

Carotid Endarterectomy: experience in 8743 cases

INTRODUCTION

Recently published case series of patients undergoing carotid endarterectomy suggested a reduction in the rate of perioperative neurologic events when compared to those reported in the large randomized trials performed in the 1990s, without great differences between high and low risk patients.

METHODS

As a major center of Vascular Surgery we prospectively collected data on 8743 carotid endarterectomy procedures (eversion technique 75%, patch closure 17.5%) performed in the period 1992-2009.

RESULTS

Perioperative mortality was 0.32% (27/8743) with myocardial infarction being the most frequent cause (9 patients). Perioperative neurological morbidity was 1.04% (91/8743) with 51 major and 40 minor strokes. In 201 cases (2.3%) a cervical hematoma (suture-line bleeding in 41 cases and or diffuse oozing in 160 cases) in the early postoperative period necessitated urgent wound revision. In 262 (3.0%) cases we observed permanent or transient lesions of cranial nerves in the postoperative period. There was no significant difference in the combined ipsilateral stroke and perioperative death rate in octogenarian patients (2.1% in octogenarians and 1.2% in younger patients, p>0.05), even though an increasing trend was evident.

CONCLUSIONS

Carotid endarterectomy has a reduced rate of perioperative complications when compared to those previously reported in literature. The low complication rate is related to improved preoperative patients evaluation, surgeons' increasing experience and to surgical and anesthesiological techniques. Carotid angioplasty and stenting should have their results compared to these real world results of carotid endarterectomy in order to asses their reliability when treating extracranial cerebrovascular disease.

Mouse vanin-1 is cytoprotective for islet beta cells and regulates the development of type 1 diabetes

AIMS/HYPOTHESIS

Islet cell death is a key initiating and perpetuating event in type 1 diabetes and involves both immune-mediated and endogenous mechanisms. The epithelial pantetheinase vanin-1 is proinflammatory and cytoprotective via cysteamine release in some tissues. We investigated the impact of a vanin-1 deficiency on islet death and type 1 diabetes incidence.

METHODS

Vanin-1-deficient mice were produced and tested in drug-induced and autoimmune diabetes models. The contribution of vanin-1 to islet survival versus immune responses was evaluated using lymphocyte transfer and islet culture experiments.

RESULTS

The vanin-1/cysteamine pathway contributes to the protection of islet beta cells from streptozotocin-induced death in vitro and in vivo. Furthermore, vanin-1-deficient NOD mice showed a significant aggravation of diabetes, which depended upon loss of vanin-1 expression by host tissues. This increased islet fragility was accompanied by greater CD4+ insulitis without impairment of regulatory cells. Addition of cystamine, the product of pantetheinase activity, protected islets in vitro and compensated for vanin-1 deficiency in vivo.

CONCLUSIONS/INTERPRETATION

This study unravels a major cytoprotective role of cysteamine for islet cells and suggests that modulation of pantetheinase activity may offer alternative strategies to maintain islet cell homeostasis.

Carotid Artery Stenosis: Intraindividual Correlations of 3D Time-of-Flight MR Angiography, Contrast-enhanced MR Angiography, Conventional DSA, and Rotational Angiography for Detection and Grading

PURPOSE

To compare three-dimensional (3D) time-of-flight (TOF) MR angiography, contrast-enhanced MR angiography, digital subtraction angiography (DSA), and rotational angiography for depiction of stenosis.

MATERIALS AND METHODS

The study had Ethics Committee approval, and each patient gave written informed consent. Forty-nine patients (18 women, mean age, 67.2 years +/- 9.1 [+/- standard deviation], and 31 men, mean age, 63.1 years +/- 8.0) with symptomatic stenosis of internal carotid artery (ICA) diagnosed at duplex ultrasonography underwent transverse 3D TOF MR angiography with sliding interleaved kY acquisition and coronal contrast-enhanced MR angiography, followed by DSA and rotational angiography within 48 hours. MR angiography was performed at 1.5-T with a cervical coil. Contrast-enhanced MR angiograms were obtained after a bolus injection of 20 mL of gadobenate dimeglumine. Maximum ICA stenosis on maximum intensity projection and source images was quantified according to NASCET criteria. Correlations for 3D TOF MR angiography, contrast-enhanced MR angiography, DSA, and rotational angiography were determined by means of cross tabulation, and accuracy for detection and grading of stenoses were calculated. Data were evaluated with analysis of variance, Wilcoxon signed rank test, and McNemar test, all at significance of P < .05.

RESULTS

Ninety-eight ICAs were evaluated at contrast-enhanced MR angiography, DSA, and rotational angiography, and 97 were evaluated at 3D TOF MR angiography. Correlations for contrast-enhanced MR angiography, 3D TOF MR angiography, and DSA relative to rotational angiography were r2 = 0.9332, r2 = 0.9048, and r2 = 0.9255, respectively. Lower correlation (r2 = 0.8593) was noted for contrast-enhanced MR angiography and DSA. Respective sensitivity and specificity for detection of hemodynamically relevant stenosis relative to rotational angiography were 100% and 90% for contrast-enhanced MR angiography, 95.5% and 87.2% for 3D TOF MR angiography, and 88.6% and 100% for DSA. Four of 31 severe stenoses were underestimated at DSA, and three were underestimated at contrast-enhanced MR angiography. Three severe stenoses were underestimated at 3D TOF MR angiography, and one was misclassified as occluded. Of 13 moderate (50%-69%) stenoses, one was overestimated at contrast-enhanced MR angiography, two were underestimated and three overestimated at 3D TOF MR angiography, and two were underestimated at DSA.

CONCLUSION

DSA results in an underestimation of ICA stenosis compared with rotational angiography. Contrast-enhanced MR angiography correlates best with rotational angiography.

Visceral Artery Aneurysms

Visceral artery aneurysms (VAA) frequently present as life-threatening emergencies. The purpose of this study was to review our experience with VAA treatment. Between 1988 and April 2002, 31 VAA were treated in 28 patients (14 males, 14 females) with average age of 55 +/- 15 years. The most common locations were the splenic artery (16) and the hepatic artery (7). Three patients underwent emergency surgery, 22 patients had elective open surgery, and 7 patients underwent endovascular treatment. In the surgical group the perioperative mortality rate was 3.6%. The perioperative morbidity rate was 7.1% (one case of respiratory distress manifested in the immediate postoperative period and one urgent case of bilious fistula). In the endovascular group none of the patients died; the perioperative morbidity rate was of 14.3% (one case of hepatic artery thrombosis after failure of gastroduodenal artery aneurysm embolization). Failure of the procedure was 42.9% (3 cases of aneurysm recanalization). In conclusion, we believe that an aggressive surgical approach is justified, even in the case of asymptomatic VAA, because of the low morbidity and mortality rates. Endovascular treatment should be reserved for selected cases.

Carotid Endarterectomy: Experience in 5425 Cases

From 1992 to December 2002, 3967 patients (2619 males; 1348 females) with a mean age of 68.4A years (range 32-92) underwent 5425 carotid endarterectomy (CE) procedures at our institute. Neurological history was positive for stroke in 1130 cases (21%) and for transient ischemic attack (TIA) in 2121 cases (39%). In 2174 cases (40%) patients were neurologically asymptomatic or presented nonspecific symptoms. Our current clinical protocol has been designed to optimize resources and reduce complications. Some of the major features, along with the respective percentages in this series, are as follows. Duplex scanning was performed at a validated laboratory as the principal preoperative exam (86.9%). Locoregional anesthesia and neurological monitoring were performed during carotid cross-clamping (96.3%). Selective shunting was carried out with a Javid shunt (10.7%). The choice of surgical technique was made according to carotid anatomy and cerebral tolerance of cross-clamping. Those used were a standard technique (now abandoned, 12.1%), synthetic patching (46.4%), and eversion endarterectomy (41.5%). Intraoperative completion arteriography was routinely performed for eversion endarterectomy and only in dubious cases with other techniques. The option of staying in an postoperative intensive care unit (ICU) was available (selective use, 2%). In uncomplicated cases, early discharge (after 1.5 postoperative days) was considered safe. The overall perioperative mortality was 0.37% (20/5425). Causes of death were myocardial infarction in seven cases, ischemic stroke in six cases, hemorrhagic stroke in five cases, respiratory failure caused by cervical hematoma in one case, and wound infection in one case. Perioperative neurological morbidity was 1.31% (71/5425); there were 43 major and 28 minor strokes. In conclusion, CE is effective for stroke prevention when there is significant symptomatic and asymptomatic carotid stenosis, as low mortality and morbidity may be achieved in an experienced center. At our institute, the reduction of costs did not have negative consequences on the quality of the surgical care.

Vanin-1-/- mice exhibit a glutathione-mediated tissue resistance to oxidative stress

Vanin-1 is an epithelial ectoenzyme with pantetheinase activity and generating the amino-thiol cysteamine through the metabolism of pantothenic acid (vitamin B(5)). Here we show that Vanin-1(-/-) mice, which lack cysteamine in tissues, exhibit resistance to oxidative injury induced by whole-body gamma-irradiation or paraquat. This protection is correlated with reduced apoptosis and inflammation and is reversed by treating mutant animals with cystamine. The better tolerance of the Vanin-1(-/-) mice is associated with an enhanced gamma-glutamylcysteine synthetase activity in liver, probably due to the absence of cysteamine and leading to elevated stores of glutathione (GSH), the most potent cellular antioxidant. Consequently, Vanin-1(-/-) mice maintain a more reducing environment in tissue after exposure to irradiation. In normal mice, we found a stress-induced biphasic expression of Vanin-1 regulated via antioxidant response elements in its promoter region. This process should finely tune the redox environment and thus change an early inflammatory process into a late tissue repair process. We propose Vanin-1 as a key molecule to regulate the GSH-dependent response to oxidative injury in tissue at the epithelial level. Therefore, Vanin/pantetheinase inhibitors could be useful for treatment of damage due to irradiation and pro-oxidant inducers.

Traumatic rupture of the thoracic aorta

Traumatic rupture of the thoracic aorta is a life threatening situation, and may be secondary to several mechanisms; mainly penetrating or iatrogenic lesions and blunt trauma. Although penetrating mechanisms predominate, the number of patients with aortic disruption due to blunt trauma has continued to increase. This paper shows an overview focusing on the pathogenesis, diagnosis, timing and type of treatment regarding traumatic injuries of the thoracic aorta; it also reports the experience of one single center that deals with these lesions. The major difficulty in the evaluation data on blunt aortic injury is that retrospective reviews often group together patients with all types of aortic lesions, comparing outcomes for injuries in different locations, with diverse methods of repair and different surgeons and/or institutions.

Carotid endarterectomy in the octogenarian: outcomes of 345 procedures performed from 1995-2000

The purpose of this study is to evaluate the efficacy and the safety of carotid endarterectomy (CEA) in the octogenarian patient. From January 1995 to December 2000, we have performed 3430 CEAs in 2743 patients: 345 CEAs in 269 octogenarian patients (Group 1) and 3085 CEAs in 2474 younger patients (Group 2). Age was the only selection criteria for including patients in Group 1. Octogenarians' perioperative mortality (1.4%) was greater than that in Group 2 (0.3%) (p<0.05). No differences can be found between the groups' perioperative ipsilateral stroke rates (1.7% in Group 1 vs 1.2% in Group 2) and combined ipsilateral stroke and death rates (2.3% in Group 1 vs 1.3% in Group 2) (p>0.05). The octogenarians' Kaplan-Meier 6-year overall and free-stroke survival rates were 86 and 76% respectively. CEA can be performed in selected octogenarian patients with low early and late mortality and neurologic morbidity rates.

Vascular prosthetic graft infection: epidemiology, bacteriology, pathogenesis and treatment

Vascular prosthetic graft infection remains a major surgical challenge. Prevention of risk factors and antibiotic therapy can reduced but not eradicate it. Management of infected vascular grafts depends on several factors, including the location of the infected prosthesis, the extent of infection, and the underlying micro-organism. Classic treatment consists of extra-anatomic bypass grafting. The disappointing results due to the high mortality and amputation rate have kindled interest in alternative approaches, such as in situ reconstruction with antibiotic-bonded prostheses, autogenous veins or arterial allografts.

PURPOSE

We focused on the treatment of aortic graft infection by means of both fresh and cryopreserved arterial allograft. Here, the experience of the Italian Collaborative Vascular Homograft Group is reported.

METHODS

Between March 1994 and December 2000 seventy-nine patients with aortic graft infection were treated. The results of 68 patients are analysed. Eleven patients were treated with fresh, and 57 with cryopreserved homograft. Emergency surgical procedures were performed in 12 patients (17%). Aortoenteric fistula was diagnosed in 22 patients. The mean interval between the first procedure and the insertion of a homograft for patients with infected aortic graft was 3 years (range 1-15). The mean duration of follow-up was 30 months (range 1-68). Clinical and duplex scanning evaluation were routinely performed. Computer tomography (CT), magnetic resonance (MR), or arteriography were performed on the basis of duplex scanning results.

RESULTS

The analysis was performed on 68 cases for which there were sufficient reliable data. Eleven deaths occurred during the early postoperative period (30 days), a mortality rate of 16%. There were also seventeen late deaths, a mortality rate of 25%. Eleven patients had graft occlusion; six cases were successfully treated with thrombectomy. In three cases leg amputation was necessary. The results of fresh and cryopreserved homografts were compared. No significant differences of early postoperative mortality, late mortality, homograft-related mortality, graft failure were observed. The presence of aortoenteric fistula is a negative predicting factor of perioperative early mortality, which causes a rapid decline in the survival curve. Thirty-six months after the surgery the actuarial survival of the patients was 57% and the actuarial patency of the allograft was 41%.

CONCLUSION

No significant difference in terms of clinical outcome was observed when using fresh, rather than cryopreserved homografts. The only factor that significantly influenced the survival rate appeared to be the aorto-enteric fistula.

Results of carotid endarterectomy performed with preoperative duplex ultrasound assessment alone

Contrast injection cerebral angiography has been considered for several decades the "gold-standard" technique for diagnosis and operative planning of carotid disease. More recently, however, an increasing number of institutions are using duplex ultrasound as the single independent preoperative test. The objective of this investigation was to evaluate the impact of the utilization of duplex ultrasonography as the only preoperative test on the outcome of the procedure. Between 1993 and 1996, the authors performed 1,149 carotid procedures. Duplex ultrasound as the only preoperative test was employed with increasing frequency in a total of 728 cases. In 1995 and 1996, a cerebral arteriogram was performed only if duplex ultrasound was technically inadequate or questionable or showed an atypical pattern of disease. During the 4 years analyzed in this study, the number of the procedures increased from 165 in 1993 to 412 in 1996. The thirty-day mortality rate was 0.43%, and neurologic morbidity was 1.65%. According to the year in which the procedure was performed, the mortality/morbidity rates were 1.2/2.4 in 1993, 0.52/2.08 in 1994, 0.26/1.57 in 1995, and 0.24/1.21 in 1996. Indication to perform an arteriogram became very selective in 1995. Regardless of these changes in the diagnostic work-up, some degree of reduction in both 30-day mortality and neurologic morbidity was recorded. Considering a cost of 724 European Currency Units (ECU) per arteriogram, 527,072 ECU were saved in this period. In the last 4 years, duplex ultrasound has replaced arteriography as the first-choice technique for preoperative assessment of carotid disease at the authors' institution. There was definitely no detrimental effect on the clinical results that, on the contrary, improved during the same period. This policy has allowed a significant reduction in the cost of the procedure and has most likely prevented several arteriography-related complications. The authors recommend this policy to all institutions in which accurate duplex ultrasound is available.

Extensible expanded polytetrafluoroethylene vascular grafts for aortoiliac and aortofemoral reconstruction

The operative experience and medium-term outcome achieved with longitudinally extensible ('stretch') expanded polytetrafluoroethylene (ePTFE) bifurcated grafts in patients undergoing aortoiliac or aortofemoral reconstruction for occlusive disease at our institution was reviewed. Between 1991 and 1998, 242 patients received a bifurcated stretch graft. Forty-one patients (17%) required an aortic endarterectomy, and 63 (26%) underwent femoral artery endarterectomy. 228 patients were followed for a mean of 32 months. One patient (0.4%) died perioperatively. The perioperative morbidity included cardiac (3.7%), respiratory (2.5%), and renal (3.3%) complications. Three patients required early reoperation for bleeding. Four (1.7%) grafts thrombosed within 24h of surgery; eight additional grafts (3.3%) thrombosed 5-8 months later. There were three postoperative aortic graft infections, one inguinal infection, three inguinal pseudoaneurysms, and one aortic pseudoaneurysm. Ultrasonography during follow-up showed no periprosthetic fluid collections or graft dilatations. The bifurcated ePTFE stretch graft is suitable for aortoiliac and aortofemoral reconstruction, and its physical characteristics may help to reduce graft-related complications.

Role of Tec kinase in nuclear factor of activated T cells signaling

The Tec protein kinase family includes Btk, Itk, Tec, Rlk and Bmx, which are critically involved in signals mediated by various cytokines and antigen receptors. Btk mutations cause severe immunodeficiencies, with defective B cell function. In T cells, Tec regulates cytokine production. However, the downstream targets of these Tec kinases are poorly defined. Here we report that overexpression of Tec in T cells can regulate gene transcription through the nuclear factor of activated T cells (NF-AT). Using different reporter gene constructs, we establish that Tec in transfected T cells dramatically induced NF-AT-dependent gene transcription, which was prevented by a dominant-negative mutant of NF-AT or by the immunosuppressive drug cyclosporin A. Tec appears to regulate NF-AT nuclear import. In addition, Tec influences cytoplasmic free calcium increase. Taken together, our results identify NF-AT as a major downstream target of Tec kinases that is critically involved in transcriptional gene regulation. These observations highlight signaling pathways regulated by Tec kinases and provide new pharmacological targets to regulate immune functions.

Antipyrine clearance in chronic and neoplastic liver diseases: a study of 518 patients

Antipyrine metabolism is widely used as an index of the drug-metabolizing reserve of the liver. It is well known that metabolism of this drug is impaired in subjects with acute hepatitis or cirrhosis, but conflicting data have been reported regarding patients with chronic postinfectious hepatitis or liver cancer. We studied conventional liver-function parameters and antipyrine metabolism (antipyrine per o.s. 18 mg/kg) in 518 subjects. One hundred and one patients had liver metastases (various primaries). Based on the number and size of lesions, the hepatic involvement was considered minimal in 47 and massive in 54 (groups B1 and B2, respectively). One hundred and two had chronic active hepatitis (CAH); 51 patients with histological evidence of fibrosis/early cirrhosis and 51 patients were without histological evidence of fibrosis/early cirrhosis. Ninety-two had histologically confirmed cirrhosis (group D), and the remaining 120 had cirrhosis and hepatocellular carcinoma (group E). The control group was composed of 103 subjects with healthy livers (group A). Antipyrine clearance (AP Cl) in CAH patients with fibrosis (0.246 +/- 0.98 mL/min per kg) was similar to that observed in patients with cirrhosis (0.223 +/- 0.148 mL/min per kg), and both values were significantly lower than that found in CAH patients without fibrosis (0.406 +/- 0.159 mL/min per kg, P < 0.01). Antipyrine clearance in patients with liver metastases (0.426 +/- 0.174 mL/min per kg) was similar to that of the healthy group (0.489 +/- 0.210 mL/min per kg). Cirrhotics and cirrhotics with hepatocellular carcinoma (HCC) presented similar degrees of impairment. Antipyrine clearance was positively correlated with serum albumin (r2 = 0.10, P = 0.01) and prothrombin time (r2 = 0.129, P < 0.01) in all groups, except those with liver metastases. In patients with CAH, the presence of fibrosis/cirrhosis is associated with impaired antipyrine metabolism. The lack of impairment in groups with liver metastases suggests that the functional hepatic reserve is maintained even in the presence of massive neoplastic invasion.

In search of biological markers of high-risk carotid artery atherosclerotic plaque: enhanced LDL oxidation

The oxidation of low density lipoprotein (LDL) is a key event in the development and progression of atherosclerosis because it generates molecular epitopes that are more atherogenic than parent LDL. We found previously that patients with carotid atherosclerosis have a significantly higher titer of autoantibodies against oxidatively modified LDL than normal subjects. The aim of this study is to correlate biological markers of in vivo LDL oxidation with the degree of carotid stenosis and of plaque ulceration (PU) in a series of patients undergoing carotid endoarteriectomy (CEA). Ninety-four consecutive patients (68M and 26F, aged 67.3 +/- 8.2 years) who underwent CEA at our institution between June 1993 and January 1994 were included in the study. The degree of carotid stenosis and the presence and extent of PU were correlated with the level of autoantibodies (IgG) against oxidatively modified LDL (Cu++-oxidized [oxLDL] or malondialdehyde derivatized LDL [MDA-LDL]), that consistently mirrors the occurrence of oxidative modifications in vivo. A statistically significant correlation (r = 0.23, p = 0.039) was found between the degree of carotid stenosis and antiMDA-LDL specific ratio (a parameter that describes the specificity of LDL towards other proteins as target for oxidative modification). A statistically significant correlation was also found between the PU score and antioxLDL IgG (r = 0.32, p = 0.011), antiMDA-LDL IgG (r = 0.25, p = 0.045) and antiMDA-LDL IgG specific ratio (r = 0.38, p = 0.002). None of the classical biochemical parameters (total, LDL and HDL cholesterol and triglycerides) correlated with the above-mentioned plaque characteristics. The results shown, support the use of biological markers of in vivo LDL oxidation (antioxidatively modified LDL autoantibody titers) to evaluate the clinical setting of high-risk carotid atherosclerosis both in screening and in follow-up studies.

Safe and cost-effective approach to carotid surgery

OBJECTIVE

To evaluate the safety and cost effectiveness of carotid surgery performed altering the perioperative protocol in an attempt to decrease resource utilisation.

SETTING

Department of vascular surgery in a large metropolitan teaching hospital in northern Italy.

DESIGN

Prospective, non-selective study.

MATERIALS AND METHODS

Three hundred and eighty carotid procedures were performed in 1995 on 343 patients (274 males, 69 females, mean age 68.2 years, range 47-86 years). The most important cost containment measures, were: (i) limiting the use of contrast arteriography to cases of dubious ultrasonographic diagnosis; (ii) routine use of loco-regional anaesthesia; (iii) postoperative admission to an intensive care unit (ICU) only in selected cases; (iv) early postoperative discharge where possible.

RESULTS

Mortality was 0.26% and neurological morbidity 1.58%. General anaesthesia was required in eight patients (2.1%), and only seven patients (1.8%) were admitted postoperatively to the ICU. Arteriography was performed in 56 cases (14.7%). The average hospital stay was 5 days with a global cost of 43,036 ECU, as compared with a cost of 6764 ECU for patients treated traditionally with routine arteriography, general anaesthesia and routine ICU admission.

CONCLUSIONS

Selective use of arteriography and ICU, routine use of loco-regional anaesthesia and reduced hospital stay make it possible to lower the cost of carotid surgery without sacrificing quality.

Is endoscopy useful for early diagnosis of ischaemic colitis after aortic surgery? Results of a prospective trial

BACKGROUND

Ischaemic colitis is an infrequent, but potentially fatal, complication of abdominal aortic surgery. Its presentation is often underestimated on account of a paucity of symptoms, thus the real incidence of ischaemic colitis may be higher.

AIM

To determine the prognostic value and sensitivity of endoscopy, early postoperative endoscopic findings were evaluated.

METHODS

Over a period of three years a prospective study was undertaken in a consecutive series of 105 patients (mean age 68.9 years, range 51-85) undergoing routine rectosigmoidoscopy within 72 hours of aortic reconstructive surgery.

RESULTS

Colonic ischaemia was found in 12 patients (11.4%); five had endoscopic evidence of mild ischaemic colitis, ulcerations were identified in five and diffuse superficial necrosis in two. Seven of the 12 patients were symptomatic. Laparotomy was never deemed necessary and all patients were successfully treated with a conservative regimen. There were no deaths. Elective reconstruction or urgent procedure did not correlate with the development of colonic ischaemia, nor did duration of aortic cross-clamp time, patency of the inferior mesenteric artery and its possible ligation or reimplantation or patency of the hypogastric arteries.

CONCLUSIONS

Rectosigmoidoscopy is effective for early diagnosis of ischaemic colitis. Early endoscopy should be routinely performed only for patients in whom impaired blood flow is suspected on the basis of the intraoperative objective assessment of the colon and in presence of symptoms.

Avidin and 111In-labelled biotin scan: a new radioisotopic method for localising vascular graft infection

OBJECTIVES

To evaluate a new imaging technique, for diagnosis of prosthetic vascular graft infection. Avidin is a protein which accumulates nonspecifically at sites of inflammation or infection. Due to its extremely low dissociation constant with biotin sites of infection can be imaged, using avidin as a pre-target, followed by injection of 111In-labelled biotin. This technique is much simpler than the common scintigraphic methods which employ labelling of blood components and its target-to-background ratio is greater than the methods employing radiolabelled proteins.

DESIGN

Prospective clinical study.

SETTING

A single department of vascular surgery and one of nuclear medicine of a Northern Italian hospital.

MATERIALS

Between May 1993 and May 1994, 31 grafts in 26 patients were studied; the series included 23 men and three women with a mean age of 65.5 years (range 54-76 years). The prosthetic graft (Dacron -16, ePTFE -15) were: aortoaortic 5, aortobifemoral 15, aortoiliac 1, and femoropopliteal 10. Sixteen patients were suspected of having a vascular graft infection (Group A), the other 10 patients served as controls (Group B). 20 mg of Avidin were injected iv, followed 24 h later by i.v. injection of 500 micrograms of Biotin labelled with 74 MBq of 111In.

CHIEF OUTCOME MEASURES

Whole-body imaging was performed at 10 min and 2 h post-injection, along with SPECT imaging when indicated. Scan results were correlated with the traditional imaging modalities and the clinical outcome of the patients.

MAIN RESULTS

In Group A: two patients (three grafts) were excluded from the study, there were six true-positives, one false-positive and 11 true-negatives. Results in Group B: 10 true-negatives. The overall sensitivity was 100%, the specificity 95%, the accuracy 96%, the positive predictive value 86% and the negative predictive value 100%.

CONCLUSIONS

These data suggest that Avidin/111In-labelled Biotin scintigraphy is a useful non invasive diagnostic method for early diagnosis of suspected prosthetic vascular graft infection.

Mural thrombi in abdominal aortic aneurysms: MR imaging characterization--useful before endovascular treatment?

PURPOSE

To evaluate magnetic resonance (MR) imaging accuracy in the characterization of mural thrombi in abdominal aortic aneurysms (AAAs).

MATERIALS AND METHODS

Forty-five patients (37 men, eight women; mean age, 68 years) with an AAA with mural thrombus thicker than 1 cm at sonography underwent T1- and T2-weighted spin-echo MR imaging. The thrombi were prospectively classified as one of three signal intensity (SI) categories: category 1 corresponds to low SI on both T1- and T2-weighted images; category 2, high SI on T1-and T2-weighted images; and category 3, inhomogeneous SI with hyperintense areas on both T1- and T2-weighted images. During surgery, thrombi were classified as organized, unorganized, and partially organized. MR imaging and surgical findings were compared.

RESULTS

SI category 1 corresponded to organized thrombi in 24 of 24 patients. Category 2 corresponded to unorganized thrombi in 11 of 11 patients. In category 3, focal hyperintense areas corresponded (both for presence and location) to unorganized portions of partially organized thrombi in 10 of 10 patients.

CONCLUSION

MR imaging is accurate in AAA thrombus characterization.

A new ePTFE stretch graft for aorto-iliac reconstructions. Surgical evaluation and one year follow-up with magnetic resonance imaging

Since its introduction at the beginning of the 60s Dacron has proved to be a reliable and durable substitute for aortic reconstructions. It is however susceptible to late thrombosis, infection and aneurysmal dilatation in a significant number of cases. ePTFE vascular prosthesis, introduced in 1972, have proved to perform well for peripheral reconstructions and was used in aortoiliac position since 1980. In 1991 a new type of ePTFE rendered longitudinally extensible (Gore-Tex Stretch) was introduced into clinical practice. The aim of this study is to evaluate surgical performance, short term patency and interaction with periprosthetic tissues of Gore-Tex Stretch straight and bifurcated prosthesis. Between October 1991 and December 1993, 59 patients underwent aortic reconstruction at our Institution either for infrarenal aortic aneurysm (19 patients, 16 males, 3 females, mean age 68.8 +/- 8.5 years) or for aortoiliac occlusive disease (40 patients, 36 males, 4 females, mean age 60.5 +/- 7.2 years). Forty-eight bifurcated and eleven straight grafts were implanted using Gore-Tex sutures. Preoperative workup included Ultrasonography, Magnetic Resonance Imaging (MRI) in patients with aneurysms and Intra Arterial Digital Subtraction Arteriography (DSA) in patients with occlusive disease. Intraoperative parameters were recorded. Postoperative follow-up included ultrasonographic evaluation at 1st and 7th day, 15th postoperative week and at 3 monthly intervals; Intra Venous DSA before dismission and MRI at the 1st and 15th postoperative week. Intraoperatively the grafts proved to be soft and flexible with good handling and suturing characteristics. Perioperative bleeding was 480 +/- 299 ml for occlusive disease cases and 633 +/- 314 for aneurysm cases. No operative mortality was recorded.(ABSTRACT TRUNCATED AT 250 WORDS)

Combined carotid endarterectomy and myocardial revascularization: personal experience

A significant percentage of patients undergoing myocardial revascularization suffer from extracranial cerebrovascular disease; recognition of such combined lesions identifies patients at risk for cerebrovascular accidents during the cardiac procedure. Simultaneous or staged coronary artery bypass graft (CABG) and carotid endarterectomy operations have been performed for the last 20 years, however, the clinical indications and the timing of the procedures remain controversial issues. Between November 1988 and January 1994, 1122 patients underwent myocardial revascularization at our Institute and in 35 cases (3.7%) carotid endarterectomy was simultaneously performed; 502 isolated carotid endarterectomies were performed in the same period. Trivascular coronary artery disease was found in 27 cases and low ejection fraction in six. Each patient received an average of 3.7 coronary grafts. Hospital mortality was 5.7% and major neurologic morbidity 2.8%. We believe that a simultaneous approach is recommended in patients with unstable angina and symptomatic carotid artery disease; in patients with a critical but asymptomatic carotid artery stenosis the indication for operation is subject to individual clinical judgment.

LDL oxidation in patients with severe carotid atherosclerosis. A study of in vitro and in vivo oxidation markers

Among the various risk factors involved in the development and progression of carotid atherosclerosis, the oxidation of LDL has been proposed to play a relevant role. LDL oxidation has been investigated in 94 patients with severe carotid atherosclerosis undergoing elective carotid artery endarterectomy and in 42 matched control subjects. LDL oxidation was evaluated in all patients as (1) the susceptibility to in vitro oxidation, (2) vitamin E concentration and its efficiency in LDL, and (3) the presence of autoantibodies against oxidatively modified lipoprotein to monitor the occurrence of the oxidative processes taking place in vivo. No difference was detected between control subjects and patients concerning vitamin E concentration and the kinetics of conjugated diene formation in isolated LDL exposed to CuSO4. However, vitamin E efficiency was lower (9.6 +/- 4.2 versus 30.2 +/- 7.6 min/nmol vitamin E) and the duration of the vitamin E-independent lag phase was longer (105.5 +/- 16.5 versus 58 +/- 11.8 minutes) in the patient group. Autoantibodies against oxidatively modified lipoproteins were measured with an ELISA method using native LDL, Cu(2+)-oxidized LDL (oxLDL), or malondialdehyde-derivatized LDL (MDA-LDL) as antigens. To monitor cross-reactivity of the antibodies detected with other oxidatively modified proteins, human serum albumin (HSA) and MDA-derivatized HSA (MDA-HSA) were also employed. The antibody titer was calculated as the ratio of antibodies against modified versus native proteins.(ABSTRACT TRUNCATED AT 250 WORDS)

[Magnetic resonance: preoperative assessment of abdominal aortic aneurysms. Comparison with surgical findings in 80 cases]

This work was aimed at assessing Magnetic Resonance (MR) accuracy in the preoperative investigation of abdominal aortic aneurysms, with a view to suggesting MRI as the method of choice for surgical planning, replacing other relatively invasive investigation techniques like angiography and enhanced CT. In the last 3 years 80 patients with abdominal aortic aneurysms identified with US or CT were examined with 0.5-T MRI and underwent surgical repair within 15 days. Spin-echo (SE) T1-weighted axial, sagittal and coronal sequences were always performed. In 18 patients gradient-echo (GE) flow sequences were also acquired; SE T2-weighted sequences were used to study parietal thrombi in 10 patients and finally Gd-DTPA T1-weighted sequences were obtained in inflammatory aneurysms (3 patients). MR images were blindly evaluated by 2 radiologists. The following variables which are useful for surgical planning were considered for each patient: aneurysm extent, characteristics of parietal thrombi, dissections, fixurations, inflammation signs, involvement of renal arteries, vena cava, ureters, duodenum, the presence of retroaortic renal vein or of other anomalies or associated conditions. MR images were always compared with intraoperative findings, since surgery was considered as the gold standard. MR findings were in agreement with surgical findings in the evaluation of cranio-caudal aneurysm extent (78/80), parietal thrombus features (80/80), dissection (1/1) and fixuration signs (8/9), origin of renal arteries (80/80), inferior vena cava involvement (3/3), other anatomical anomalies or conditions (6/6). Inflammation signs were overestimated (14/8) as well as adhesion between aneurysm and duodenum (17/13). The presence of distal renal polar arteries was underestimated (2/4). In conclusion, MRI proves to be a highly sensitive method to demonstrate abdominal aortic aneurysms and is therefore suggested as the examination of choice before surgery.

Three dimensional time-of-flight magnetic resonance angiography in carotid artery surgery: a comparison with digital subtraction angiography

Three dimensional time-of-flight magnetic resonance angiography (MRA) and intra-arterial digital subtraction angiography (DSA), considered the gold-standard technique, were compared for pre- and postoperative evaluation of the carotid bifurcation. Images of suitable quality of 194 bifurcations were available with both techniques. Percentage stenosis was graded into 5 groups: A = 0-29%, B = 30-59%, C = 60-89%, D = 90-99%, E = 100% (occlusion). Preoperative MRA (126 bifurcations) overgraded the stenosis in 14 cases and undergraded it in 11. The two techniques agreed in 101 cases and the extent of misgrading was never more than one category. Regression analysis showed a good correlation between the two methods. Severe ulceration was better identified by DSA. As far as the surgical indication was concerned, MRA had a sensitivity of 92.6% and a specificity of 98.3%. In 68 operated cases, postoperative MRA and intraoperative completion angiography showed a satisfactory endarterectomy with no residual stenosis in any of the cases. In conclusion, MRA seems an accurate modality for imaging of carotid bifurcations. Significant limitations still exist for an adequate demonstration of intracranial circulation.

Antipyrine metabolism in patients with liver metastases from colorectal cancer

BACKGROUND

The influence of cancer on antipyrine metabolism is under debate.

METHODS

To assess the functional activity of a liver with solid metastases from primary colorectal cancer, antipyrine metabolism was studied after the drug was administered orally (18 mg/kg body weight) to 55 healthy volunteers, 62 patients with well-compensated cirrhosis, and 42 patients with small (Class A) or massive (Class B) metastatic liver involvement.

RESULTS

In patients with cancer, antipyrine clearance (0.472 +/- 0.177 ml/min/kg) was similar to that in healthy volunteers (0.456 +/- 0.198 ml/min/kg) and significantly higher than in those with cirrhosis (0.259 +/- 0.17 ml/min/kg, P less than 0.001). There was no difference in antipyrine pharmacokinetics between Class A and B involvement. In the entire population, antipyrine clearance was correlated with serum albumin levels (r = 0.294, P = 0.0002) and prothrombin activity (r = 0.416, P = 0.001). This positive correlation was not present when only the neoplastic group was considered. No correlation was found between antipyrine clearance and alkaline phosphatase levels. In patients with cancer, no relationship was found between antipyrine clearance and carcinoembryonic antigen and lactic dehydrogenase levels.

CONCLUSIONS

These results show that patients with livers largely replaced by solid metastases are able to metabolize antipyrine to the same extent as healthy subjects.