Tracheostomy decannulation in severe acquired brain injury patients: The role of flexible bronchoscopy.

INTRODUCTION AND OBJECTIVES: Subjects with severe acquired brain injury (sABI) require long-term mechanical ventilation and, as a consequence, the tracheostomy tube stays in place for a long time. In this observational study, we investigated to what extent the identification of late tracheostomy complications by flexible bronchoscopy (FBS) might guide clinicians in the treatment of tracheal lesions throughout the weaning process and lead to successful decannulation. SUBJECTS AND METHODS: One hundred and ninety-four subjects with sABI admitted to our rehabilitation unit were enrolled in the study. All subjects received FBS and tracheal lesions were treated either by choosing a more suitable tracheostomy tube, or by laser therapy, or by steroid therapy, or by a combination of the above treatments. RESULTS: Overall, 122 subjects (63%) were decannulated successfully. Our subjects received 495 FBSs (2.55 per subject) and as many as 270 late tracheostomy complications were identified. At least one complication was found in 160 subjects (82%). In only 11 subjects, late tracheostomy complications did not respond to the treatment and were the cause of decannulation failure. CONCLUSIONS: In conclusion, in sABI patients FBS is able to guide successful tracheostomy weaning in the presence of late tracheostomy complications that could get in the way decannulation.

Independent Functioning in Nonagenarians Living in a Rural Italian Community: The Mugello Study.

Nonagenarians are a fast-growing population deserving specific research. We explored the prevalence and characteristics of functionally independent nonagenarians from a rural community-dwelling Italian population. Data were collected in the Mugello Study; 475 persons aged ≥90 years (median age, 92) underwent a home-based clinical and functional assessment, including psychosocial, clinical, functional, and lifestyle history and status and physical and instrumental examinations. Sixty-eight (15%) persons reported no need for help in basic and instrumental daily living activities. Among variables significantly associated with independent functionality after age- and gender-adjusted cross-sectional analysis, lower body mass index (BMI; p = .034) and depressive symptoms (p = .028), higher current physical activity (p < .001), better cognitive status (p = .033), and lower medication intake (p = .048) were associated with reporting no disability in the logistic regression analysis. Disability was mainly associated with current lifestyle-related potentially modifiable factors. Thus, lifestyle-oriented multidimensional interventions, should be developed and evaluated for their potential effects on functionality, even in the oldest old.

Mediterranean Diet, Food Consumption and Risk of Late-Life Depression: The Mugello Study.

OBJECTIVES: To investigate eating habits and adherence to Mediterranean Diet (MD) in relation to the risk of depression in a cohort of nonagenarians enrolled within the Mugello Study, an epidemiological study aimed at investigating both clinically relevant geriatric items and various health issues, including those related to nutritional status. DESIGN: Cross-sectional study. SETTING: Homes and nursing homes in the Mugello area, Florence, Italy. PARTICIPANTS: Subjects aged 90-99 years [N=388 (271F; 117M) mean age: 92.7±3.1]. MEASUREMENTS: All subjects were evaluated through questionnaires and instrumental examinations. Adherence to MD was assessed through the Mediterranean Diet Score. A shorter version of the Geriatric Depression Scale (GDS) was used to detect the possible presence of depressive symptoms. In addition, cognitive and functional status was assessed using the Mini-Mental State Examination, the Clock Drawing Test, as well as the Basic and Instrumental Activities of Daily Living test. RESULTS: Depressed subjects (DS) (GDS score≥5, 43.8%) were older, females and widows, than non-depressed subjects (NDS). DS reported a slightly but not statistically significant lower MD score than NDS (33.9±3.9 vs. 34.6±3.3, p=0.149). Subjects who reported to consume a greater amount of olive oil and fruit were associated with a lower risk of depression (OR=0.35, 95%CI=0.20-0.59, p<0.001 and OR=0.46, 95%CI=0.26-0.84, p=0.011, respectively) after adjustment for many possible confounders. Similar results were obtained for women, while no statistically significant differences emerged for men. CONCLUSION: Our results support the hypothesis that a diet rich in olive oil and fruit, characteristics of MD, may protect against the development of depressive symptoms in older age.

Aging process, adherence to Mediterranean diet and nutritional status in a large cohort of nonagenarians: Effects on endothelial progenitor cells.

BACKGROUND AND AIM: Adherence to the Mediterranean Diet (MD) has been associated with a longer and better life. The aim of this study was to examine the effects of adherence to the MD, and of nutritional habits on endothelial progenitor (EPCs) and circulating progenitor (CPCs) cells in a cohort of nonagenarians enrolled within the Mugello Study, an epidemiological study aimed at investigating both clinically relevant geriatric items and various health issues, including those related to nutritional status. METHODS AND RESULTS: Four hundred twenty-one nonagenarians (306 F, 115 M, mean age: 93.1 ± 3.2 years) were evaluated. Adherence to MD was assessed through the Mediterranean Diet Score. Elderly subjects who were in the fourth quartile of the Mediterranean diet score showed significantly higher EPCs than subjects grouped into the other three quartiles. After adjustment for confounders, elderly subjects who were in the highest quartile of adherence to the MD score reported to have EPCs' levels significantly higher than those who reported lower values of adherence to the MD. Furthermore, by analyzing different food categories, it was reported that daily consumption of olive oil and a higher consumption of fruit and vegetables showed higher CPCs CD34+ and EPCs CD34+/KDR+ than subjects with not daily or lower consumption. CONCLUSION: Our results support the hypothesis that the adherence to MD, as well as a daily consumption of olive oil and fruit and vegetables, characteristics of MD, may protect against the development of endothelial dysfunction through increasing EPCs and CPCs in older age.

An ecologically-controlled exoskeleton can improve balance recovery after slippage.

The evolution to bipedalism forced humans to develop suitable strategies for dynamically controlling their balance, ensuring stability, and preventing falling. The natural aging process and traumatic events such as lower-limb loss can alter the human ability to control stability significantly increasing the risk of fall and reducing the overall autonomy. Accordingly, there is an urgent need, from both end-users and society, for novel solutions that can counteract the lack of balance, thus preventing falls among older and fragile citizens. In this study, we show a novel ecological approach relying on a wearable robotic device (the Active Pelvis Orthosis, APO) aimed at facilitating balance recovery after unexpected slippages. Specifically, if the APO detects signs of balance loss, then it supplies counteracting torques at the hips to assist balance recovery. Experimental tests conducted on eight elderly persons and two transfemoral amputees revealed that stability against falls improved due to the "assisting when needed" behavior of the APO. Interestingly, our approach required a very limited personalization for each subject, and this makes it promising for real-life applications. Our findings demonstrate the potential of closed-loop controlled wearable robots to assist elderly and disabled subjects and to improve their quality of life.

Higher uric acid serum levels are associated with better muscle function in the oldest old: Results from the Mugello Study.

BACKGROUND: Sarcopenia is the progressive loss of muscle mass and strength that occurs with advancing age and plays a pivotal role in the causal pathway leading to frailty, disability and, eventually, to death among older persons. As oxidative damage of muscle proteins has been shown to be a relevant contributory factor, in this study we hypothesized that uric acid (UA), a powerful endogenous antioxidant, might exert a protective effect on muscle function in the oldest old and we tested our hypothesis in a group of nonagenarians who participated in the Mugello Study. METHODS: 239 subjects, 73 men and 166 women, mean age 92.8years±SD 3.1, underwent the assessment of UA serum level and isometric handgrip strength, a widely used clinical measure of sarcopenia. RESULTS: Mean UA serum level was 5.69mg/dL±SD 1.70 and mean handgrip strength was 15.0kg±SD 6.9. After adjusting for relevant confounders, higher UA serum levels remained independent positive predictors of isometric handgrip strength (ß 1.24±SE(ß) 0.43, p=0.005). CONCLUSION: Our results show that higher UA serum levels are associated with better muscle function in the oldest old and, accordingly, might slow down the progression of sarcopenia.

Higher uric acid levels are associated with better functional recovery in elderly patients receiving cardiac rehabilitation.

BACKGROUND AND AIMS: Whether uric acid (UA) serves as risk factor for cardiovascular diseases or as antioxidant defense has not yet been completely clarified. In this study we investigated the effects of UA on functional recovery in patients receiving cardiac rehabilitation. METHODS AND RESULTS: 306 patients, 209 men and 97 women, age range 25-87 years (mean 68 ± 11), performed the 6-min walk test (6mWT) before and after the rehabilitation, and the increase in walking distance was considered as the outcome measure of the study. Baseline UA serum levels ranged from 1.0 to 10.9 mg/dL (mean 5.2 ± 1.7). As there was a significant (p = 0.005) age*UA levels interaction, patients were divided into two subgroups, less then 65 years (n. 103, 68 men and 35 women, mean age 56 ± 9) and 65 years or more (n. 203, 141 men and 62 women, mean age 74 ± 5). After adjusting for relevant confounders, higher UA levels remained independent positive predictors of the increase in walking distance in older (p < 0.001) but not in younger patients (p = 0.807). CONCLUSIONS: Our findings show an independent association of higher UA levels with better functional recovery after cardiac rehabilitation selectively in elderly patients, suggesting that higher UA levels might reflect the decline in antioxidant defenses that occurs with advancing age. Future studies aimed at understanding the several contradictions concerning UA should, probably, address the issue within this perspective.

Predictors of functional outcome in patients with chronic low back pain undergoing back school, individual physiotherapy or spinal manipulation.

BACKGROUND: Recent studies on chronic low back pain (cLBP) rehabilitation suggest that predictors of treatment outcome may be differ according to the considered conservative treatment. AIM: To identify predictors of response to back school (BS), individual physiotherapy (IP) or spinal manipulation (SM) for cLBP. POPULATION: outpatients with cLBP. SETTING: Outpatient rehabilitation department. DESIGN: Retrospective analysis from a randomized trial. METHODS: Two hundred and ten patients with cLBP were randomly assigned to either BS, IP or SM; the Roland Morris Disability Questionnaire (RM) was assessed before and after treatment: those who decreased their RM score <2.5 were considered non-responders. Baseline potential predictors of outcome included demographics, general and cLBP history, life satisfaction. RESULTS: Of the 205 patients who completed treatment (140/205 women, age 58+14 years), non-responders were 72 (34.2%). SM showed the highest functional improvement and the lowest non-response rate. In a multivariable logistic regression, lower baseline RM score (OR 0.82, 95% CI 0.76-0.89, P<0.001) and received treatment (OR 0.32, 95% CI 0.21-0.50, P<0.001) were independent predictors of non-response. Being in the lowest tertile of baseline RM score (<6) predicted non response to treatment for BS and IP, but not for SM (same risk for all tertiles). CONCLUSIONS: In our patients with cLBP lower baseline pain-related disability predicted non-response to physiotherapy, but not to spinal manipulation. CLINICAL REHABILITATION IMPACT: Our results suggest that, independent form other characteristics, patients with cLBP and low pain-related disability should first consider spinal manipulation as a conservative treatment.

Adaptive physical activity and back pain: a non-randomised community-based intervention trial.

BACKGROUND: Back pain is a significant problem due to the high healthcare utilization, rising costs of care and low effectiveness of many current treatments. AIM: Aim of this study was to determine the effects of a community-based Adapted Physical Activity (APA) program focused on chronic, non-specific back pain. DESIGN: Open-label intervention study. SETTING: Community. POPULATION: All patients admitted to Empoli Rehabilitation Department for non-specific back pain for at least three months, were considered for APA. Exclusion criteria were: "red flags", difficulty/disability in basic daily living activities, severe/acute medical conditions, acute pain, psychiatric disease or cognitive impairment, severe visuoauditory deficit. Overall, 650 persons were enrolled. METHODS: The APA program, including strength and flexibility training and exercises for improving posture was delivered for 12 months, with 1-hour group classes three times per week. RESULTS: Overall 261 (40.2%) subjects completed the 12-month APA program and were compared to the 310 (47.7%) who were screened but failed to initiate or complete the study. There were no significant differences in baseline demographic and clinical characteristics between groups. Patients who followed the APA program reported significantly improved health status and significant back pain improvement, compared with those who did not adhere to the program. In the logistic regression analysis adjusted for age and gender, a distance from home to gymnasium greater than the median for the study population (2.6 km) was the only baseline characteristic significantly associated with an increased risk of non-adherence (OR 1.44, 95%CI 1.01-2.13; P=0.04). CONCLUSION: This study suggests that a community-based APA program can improve back pain and health status in persons with chronic, non-specific low back pain. CLINICA REHABILITATION IMPACT: These findings highlight the potential for new approaches to manage chronic disease and disability by facilitating a healthy lifestyle and promoting physical activity through implementation of community-based exercise programs.

High sensitivity C-reactive protein predicts the development of new carotid artery plaques in older persons.

BACKGROUND AND AIM: Previous studies have shown that increased levels of C-reactive protein (CRP) predict cardiovascular events, including stroke, myocardial infarction and death from cardiovascular causes. Previous studies have also shown that increased levels of CRP are strong predictors of the progression of pre-existing carotid artery plaques. However, whether CRP is involved in the development of new plaques, that may or may not be associated with clinical events, in subjects with clean carotid arteries has been scarcely investigated. METHODS AND RESULTS: 486 "InCHIANTI" Study participants (200 men and 286 women, 72% aged 65 years and over) free from carotid artery plaques at baseline, also underwent carotid artery scan three years later. We tested the association of baseline characteristics, cardiovascular risk factors and inflammatory markers with the development of new carotid artery plaques. Older participants were significantly more likely to develop new plaques. Independent of age, the relative risks of developing new plaques associated with heavy smoking and family history of atherosclerosis were 1.7 (95%CI 1.5-1.9) and 1.9 (95%CI 1.2-3.1), respectively. Participants with high (>3 µg/mL) and moderate (≥1 and ≤3 µg/mL) CRP levels had a relative risk of 2.2 (95%CI 1.9-2.6) and 1.9 (95%CI 1.6-2.3) respectively, when compared with subjects with low (<1 µg/mL) CRP levels. Surprisingly, risk factors such as hypertension, diabetes, dyslipidemia and overweight/obesity were not significant predictors of the development of new carotid artery plaques. CONCLUSIONS: High CRP levels independently predict the development of new plaques in older persons with carotid arteries free from atherosclerotic lesions.

Environmental effects on school age child psychomotricity.

AIM: This study had the following aims: to verify whether children living in different environmental areas present a different development degree of the functional prerequisites of psychomotricity; to test whether a targeted psychomotricity education program could favourably modify the potential differences which may be observed; to investigate the relationship, if any, between the anthropometric differences and the functional prerequisites of psychomotricity. METHODS: One hundred and sixty-five Italian children, 83 males and 82 females, 6-7 years old were enrolled in this study. Based on the provenance area, the children were subdivided into two groups: the urban one (N=85) and the rural one (N=80). Both groups underwent an initial psychomotor assessment including standardised psychomotor tests aimed at evidencing the general dynamic coordination ability and the static and dynamic balance capacity of every child. RESULTS: The findings of this research point out that children living in an urban setting selectively showed a lower degree of balance development, if compared to children living in rural areas; a targeted psychomotor education program favourably modified the differences in the balance development between the two examined groups, up to their disappearance. In the urban group the body mass index had a trend towards a negative relationship with balance development. CONCLUSION: Children grown up in an urban environment showed a delay in balance development, if compared to children of the same age grown up in rural areas. This study also clearly proves that such a delay may be regained by means of a targeted psychomotor education program.

Epidemiology of hip and knee pain in a community based sample of Italian persons aged 65 and older.

OBJECTIVE: To describe prevalence, characteristics and correlates of hip pain (HP) and knee pain (KP) in an Italian community based cohort aged 65 and older (65+). METHOD: Baseline survey (1998-2000), population-based study in the Chianti area (Tuscany, Italy); 1299 persons aged 65+ were selected from the city registry of Greve in Chianti and Bagno a Ripoli (multistage sampling method); 1006 participants (564 women and 442 men, age 75.2+/-7.1) provided information for this analysis. Persons reporting HP/KP in the past 4 weeks were recorded and their Western Ontario and McMaster University Osteoarthritis Index pain score (WPS-range 0-20) calculated. Potential correlates of HP/KP, including clinical, lifestyle and psycho-social features and physical measures, were tested in age- and gender-adjusted regression analyses and then entered a multivariate regression model. RESULTS: HP was reported by 11.9% participants, while 22.4% reported KP and 7.2% both conditions. Climbing/descending stairs and walking were the activities eliciting more severe pain in either condition. Average WPSs were 5.6+/-3.5 for HP and 5.4+/-10.4 for KP. Both HP and KP were related to back pain, reduced hip abduction, reduced muscle power and increased trunk flexibility. HP was also related to KP and poor self-rated health (SRH), while KP to HP, foot pain, high body mass index, reduced knee passive flexion and knee extension torque, low education. CONCLUSION: In a community sample of an Italian persons aged 65+, the prevalence of KP almost doubled that of HP. While both conditions were related to pain in other joints and specific joint impairment, only HP was related to poor SRH, and only KP to mechanical overload.

Eating habits in elderly diabetic subjects: assessment in the InCHIANTI Study.

BACKGROUND AND AIMS: Nutritional therapy is a cornerstone of the treatment of type 2 diabetes. The aim of this study was to assess differences in dietary habits between subjects with and without known type 2 diabetes. METHODS AND RESULTS: In a sample of 1242 predominantly elderly subjects enrolled in the InCHIANTI study, total energy and macronutrient intake was assessed cross-sectionally using the EPIC self-reported questionnaire. Results were compared in subjects with (N=109) and without known diabetes, and differences were adjusted for age, sex, and reported comorbidities. Subjects with known diabetes reported a significantly lower (p<0.001) total energy and soluble carbohydrate intake in comparison with the rest of the sample (1793+/-481 vs 2040+/-624 kCal/day, and 66.9+/-22.3 vs. 93.5+/-34.9 g/day, respectively). Conversely, consumption of total and saturated fats, dietary fibres and proteins was not significantly different. CONCLUSION: Known diabetes is associated with a reduction of soluble carbohydrate consumption and total energy intake without any further modification of dietary habits. These data suggest that the diagnosis of diabetes could induce some changes in nutritional style. However, corrections in dietary habits do not appear to be consistent with current guidelines and recommendations.

Relationship between physical activity and cardiovascular disease. Selected historical highlights.

The full awareness that physical exercise represents a form of prevention and therapy for cardiovascular diseases is rather recent, considering that the discovery of blood circulation dates back to the 17th century and that the definition of major cardiovascular risk factors is an acquisition of the 20th century. In this paper a historical review has been undertaken so as to evidence major selected highlights of cardiovascular knowledge applied to physical activity from antiquity to the present day. Despite of the fact that the role of physical activity for the sake of a good body equilibrium is an ancient concept, as documented by the recurrent term ''exercise'' in the works of Hippocrates, only about 70 years have passed from the time when, in the '30s, myocardial infarction patients were strictly advised to observe a period of bed rest of at least 6 weeks; less than a century has passed since the so-called ''chair therapy'' constituted the cornerstone of the therapy of the cardiovascular patient. In the '40s and the '50s a certain amount of attentive mobilization proved to be beneficial, given that it was associated with a remarkable reduction of thromboembolic risk. In the '70s an increasing amount of clinical literature documented that even healthy subjects, remaining in bed for a long period, showed relatively rapidly signs of de-conditioning. In 1973 Kavanagh et al. demonstrated that the patients included in cardiac rehabilitation showed an improvement in their physical work capacity, an increase in their global cardiovascular function and went back more quickly and safely to their work environment, as compared with cardiac patients not performing rehabilitative physical exercise. The studies performed in the '70s provided the bases of modern cardiovascular rehabilitation, a multidimensional and integrated approach, one of whose pillars is structured physical activity.

Hemodynamics of the sapheno-femoral complex: an operational diagnosis of proximal femoral valve function.

AIM: A significant relationship between great saphenous vein (GSV) caliber at the thigh and function of the terminal valve of the sapheno-femoral junction (SFJ) has already been demonstrated. Yet, the function of the proximal common femoral valve (FV), which is missing in 20-24% of cases, might also play a significant role in SFJ reflux. The aim of this paper was to verify whether GSV caliber also predicts the function/presence of FV. METHODS: Using a high-resolution duplex scanner we selected 572 GSVs showing clear-cut SFJ incompetence. Then, by positioning the probe on the inguinal skin fold and orientating the probe upward, we tested FV function. Valve incompetence was diagnosed when a retrograde flow lasting longer than 0.5 s was elicited by both calf squeezing with sudden release and Valsalva maneuver, with the patient standing. Finally, in all patients we measured GSV caliber 15 cm below the groin in the standing position. RESULTS: GSV caliber =7 was not predictive of FV function/presence (51.9% competence vs 48.1% incompetence/absence). In contrast, GSV caliber < or = 6 mm and GSV caliber > or = 8 mm were highly predictive of FV competence and incompetence/absence, respectively (sensibility 98.6%, specificity 80.4%, positive predictive power 88.2%, negative predictive power 97.4%, diagnostic accuracy 91.3%). CONCLUSIONS: Our data strengthen the relationship between GSV caliber at the thigh and hemodynamics of the whole sapheno-femoral complex, including in this definition the FV also.

Ozone chemonucleolysis in non-contained lumbar disc herniations: a pilot study with 12 months follow-up.

STUDY DESIGN: Prospective case series with six and twelve months follow up. OBJECTIVE: To observe clinical and morphological results of the intradiscal ozone chemionucleolysis in patients affected by non-contained lumbar disc herniations. METHODS: 30 patients were included in the study on the base of precise inclusion and exclusion criteria. The patients were followed on 6 and 12 months period by Visual Analogic Scale (VAS), Roland Morris Disability Questionnaire (RMDQ) and Overall Patient Rating Scale (OPRS). Disc herniation volume morphology was evaluated at 5 months by control MRI scanning. RESULTS: Twenty-seven patients (90%) showed a statistically significant improvement in pain (P < 0.001, Wilcoxon test) and function (P < 0.001, Wilcoxon test), on VAS and RMDQ evaluation, respectively. The mean satisfaction with the treatment on OPSR was 79.3%, with 24 patients referring satisfaction equal or greater than 80%. There were no major complications related to the procedure. CONCLUSIONS: The results of this study indicate the ozone chemonucleolysis as a possibly effective modality of treatment in patients affected by signs and symptoms of non-contained lumbar disc herniations that have overpassed conservative measures and have not yet fulfilled the indications for open surgical treatment.

Hemodynamics of the sapheno-femoral junction. Patterns of reflux and their clinical implications.

AIM: The detection of reflux elicited by the compression/release test with the PW Doppler sample at the level of the sapheno-femoral arch might not be sufficient by itself to diagnose the incompetence of the whole sapheno-femoral junction (SFJ). The aim of this study was to further refine the diagnosis by positioning the PW Doppler sample at different levels of SFJ and eliciting reflux both by squeezing and with the Valsalva manoeuvre. In addition, the relationship of the findings with the vein diameter was taken into consideration. METHODS: By using a high resolution duplex scanner, 1 294 great saphenous veins (GSV) found to be incompetent by the compression/release test at duplex investigation of the saphenous arch, were also tested at the same level by the Valsalva manoeuvre. Subsequently, the tests were repeated by positioning the PW Doppler sample at the femoral side of the terminal valve, at the saphenous arch tributaries, and at the pre-terminal valve level. Furthermore, the GSV diameter in the standing position was measured at 15 cm from the groin in all patients, and correlated with the hemodynamic patterns found at the junction level. RESULTS: Comparing to compression/release test at the level of the saphenous arch, the Valsalva manoeuvre was negative in 259 (20%) lower limbs and positive in 1 035 (80%). Among the 1 294 GSV found to be incompetent at compression/release test at the level of the saphenous arch, only 710 (55%) lower limbs showed incompetence of the terminal valve. A total of 124 patients (10%), presenting with a competent terminal valve but with a positive Valsalva manoeuvre in the arch, showed a downward flow from a pelvic tributary of the GSV. Finally, a significant statistical correlation between the presence of a competent terminal valve and a GSV diameter <5 mm has been found (p<0.001). CONCLUSION: Our data show that the detection of reflux elicited by compression/release test at the level of the saphenous arch is insufficient to diagnose the incompetence of the terminal valve. Our results, together with the correlation between the saphenous trunk diameter at the thigh and the competence or the incompetence of the terminal valve, present significant clinical implications when sapheno-femoral surgical disconnection is contemplated.

Relationship between the calibre of carotid arteries and the configuration of the circle of Willis in healthy older persons.

AIM: Recent papers have pointed out that the severity of brain damage that follows carotid occlusion is largely influenced by the state of integrity and functionality of the circle of Willis. In spite of this, duplex scanning investigation of carotid arteries has traditionally been focused on the assessment of the degree of the stenosis, while other features, such as the calibre of carotid arteries and their possible asymmetry, have often been neglected. The aim of the present paper was to verify, in a cohort of older persons, whether, based on the calibre of internal carotid arteries and their possible asymmetry, abnormalities of the circle of Willis can be predicted. Such information could be used to identify high risk patients in whom the status of the circle of Willis should be investigated by MR angiography. METHODS: We studied 118 healthy older persons with both duplex scanning investigation of carotid arteries and MR angiography of the circle of Willis. RESULTS: We found that the finding of abnormal internal carotid artery calibres was always associated with abnormalities of the precommunicating segments either of the anterior or of the posterior cerebral arteries. Abnormalities of communicating arteries did not affect the calibre of internal carotid arteries, but abnormalities of anterior communicating arteries could always be detected by contralateral common carotid artery compression manoeuvres. CONCLUSION: In conclusion our findings show that, in healthy older persons, duplex scanning investigation of carotid arteries may provide useful information about the integrity and functionality of the circle of Willis. Future studies should confirm our findings in patients with atherosclerotic lesions of internal carotid arteries.

Collateral circulation in internal carotid artery occlusion. A study by duplex scan and magnetic resonance angiography.

BACKGROUND: Clinical effects of internal carotid artery (ICA) occlusion may range from the absolute absence of symptoms to lethal hemispheric stroke. In this paper symptoms of patients with ICA occlusion have been related to the development of collateral circulation, different types of developed collateral circulation have been assessed, and the degree of sensitivity and specificity of duplex scan has been appraised. METHODS: Forty-eight patients with ICA occlusion or subocclusion, 24 males and 24 females, aged between 50 and 83 years (67.7+/-7.15), underwent duplex scan and magnetic resonance (MR) angiography. Nineteen patients were completely asymptomatic, 20 patients showed permanent neurological symptoms and 9 patients had shown transient symptoms. RESULTS: Twelve patients (25%) did not show any collateral circulation, 29 patients (60%) showed collateral circulation through homolateral external carotid artery branches and 7 patients (15%) showed collateral circulation through other circuits. Of the 20 patients with permanent symptoms only 8 showed collateral circulation. On the contrary, all the 19 asymptomatic patients and the 9 patients with transient symptoms showed collateral circulation. Eventually, duplex scan showed 78% sensitivity, 100%, specificity and 83% diagnostic accuracy. CONCLUSIONS: Our data show: 1) a clear-cut prevalence of collateral circulation through homolateral external carotid artery branches with respect to other possible collateral circulation; 2) an inverse relationship between the development of collateral circulation and the appearance of permanent symptoms; 3) a good diagnostic accuracy of duplex scan in revealing collateral circulation in the case of ICA occlusion.

Macroscopic anatomy of the superficial veins of the lower limb: a systematic review based upon echography.

Saphenous Veins are described in Anatomy textbooks as superficial veins running in the amorphous fatty layer of the lower limbs. Recent papers have demonstrated the complex fascial relationship of Saphenous Veins with the connective framework of the lower limb hypodermis. The aim of the present paper was to systematically review the anatomy of lower limb superficial veins, based upon echographic findings, in a series of normal subject. Our results offer new insight into lower limbs superficial veins anatomy, with important clinical and surgical implications.