Arterial wall thickness and blood pressure in children who were born small for gestational age: correlation with umbilical cord high-sensitivity C-reactive protein.

BACKGROUND: Small for gestational age (SGA) infants have an increased risk of later cardiovascular disease. At birth, high sensitivity-C reactive protein (hs-CRP), a prognostic marker of cardiovascular disease, is significantly higher in SGA than in appropriate for gestational age (AGA) infants. AIM: To measure aortic and carotid intima-media thickness (aIMT, cIMT) and blood pressure (BP) in children (aged 3-5 years) who were born SGA and AGA, and to assess the correlation between hs-CRP concentrations obtained at birth and these haemodynamic variables. METHODS: Umbilical cord hs-CRP concentrations were obtained in 38 neonates. In the same subjects aged 3-5 years, aIMT and cIMT were measured by high-resolution ultrasound scan, in the dorsal arterial wall. Anthropometric variables and BPs were obtained for each child. RESULTS: Maximum (median 0.700 mm, range 0.500-1.080 vs 0.650 mm, 0.400-0.860; p = 0.32) aIMTs were similar between children who were born SGA (n = 17) and AGA (n = 21), respectively. Concentrations of hs-CRP were not correlated with IMTs. In children who were born SGA, systolic BP was significantly correlated with umbilical cord hs-CRP concentrations (r = 0.60; p = 0.009). CONCLUSIONS: Children who were born SGA have a higher, although not significant, aortic thickening than those who were born AGA. Umbilical cord hs-CRP concentrations do not seem to be involved in this process. Instead, hs-CRP concentrations were significantly related to systolic BP values in children who were born SGA, suggesting that hs-CRP at birth could be associated with sympathetic system hyperactivity and with the stress response during childhood.

Isolated distal deep vein thrombosis: efficacy and safety of a protocol of treatment. Treatment of Isolated Calf Thrombosis (TICT) Study.

AIM: The optimal treatment of isolated distal deep vein thrombosis (ID-DVT) is still controversial. A complete anticoagulation as soon as the diagnosis is made is recommended by some authors. Alternatively, other authors suggest to perform serial ultrasonography assessments to detect the possible extension of DVT towards proximal veins. Only in this case the treatment should be initiated. Furthermore, the optimal duration of treatment is far from established. The Treatment of Isolated Calf Thrombosis (TICT) study was set up to assess the efficacy and safety of a particular treatment regimen of ID-DVT based on low molecular weight heparins (LMWH). METHODS: The drug treatment consisted of a twice-daily subcutaneous administration of a full dose of weight-adjusted LMWH for one week, followed by a half dose of LMWH administered once-daily for another three weeks. At the end of the four-week period of treatment, a colour-coded Doppler ultrasonography (CCDU) assessment was scheduled and after three months a follow-up visit was performed. If a patient was unable to attend the visit, he was contacted by a phone-call to assess if any adverse events occurred. The study enrolled 192 outpatients with ID-DVT confirmed by CCDU. Twenty-one out of 192 patients (10.9%) were excluded for violation of protocol. Thus 171 (39.9% men, mean age of 60.45 years ) were eligible and were included in the study. Sixty-one patients (36.6%) presented an unprovoked ID-DVT. RESULTS: Events during the period of treatment (4 weeks). Ten out of 171 patients (5.8%) had complications: five patients showed an extension proximal to the knee (2.9%) all with an unprovoked ID-DVT; two showed an extension of thrombus within the distal veins. Three patients (1.7%) suffered from minor bleeding; there was no major bleeding. Further events during three months of observation occurred. Five patients had thrombus recurrences: four patients showed a proximal DVT (3 with a previous unprovoked ID-DVT, 1 with a previous ID-DVT secondary to a traumatic leg fracture, with persistent difficulty of deambulation); one, with a previous secondary thrombosis, showed a ID-DVT. CONCLUSIONS: In our study only 2.9% of patients with ID-DVT showed a progression of thrombosis to proximal deep veins; the majority of thrombus progression, during the treatment period, was observed in patients with unprovoked ID-DVT. Our results support the usefulness of a prolonged treatment in unprovoked ID-DVT.

Occult atherosclerosis and physical vascular examination: a simple strategy to avoid inadequate cardiovascular prevention and under-use of diagnostic vascular guidelines in outpatients. A multicenter study by Angiology Care Units in North-Eastern Italy.

AIM: Recent studies show a high prevalence of inadequate secondary prevention in a subset of the US population at highest risk for stroke and acute myocardial infarction. METHODS: The present investigation evaluated subjects older than 50 years of age attending four Angiology Care Units in Northern Italy. The adequacy of risk factor (hypertension, body weight, cigarette smoking and hypercholesterolemia) control was in particular analyzed, and a search was made for occult atherosclerotic lesions during a thorough physical examination. Finally, adherence to diagnostic vascular guidelines was also evaluated. RESULTS: Twenty-two percent out of 483 patients enrolled in this study were found to have unexpected atherosclerotic lesions, 61.9% of the patients with a history of hypertension, 10.6% showed an inadequate control of blood pressure levels, 55% presented poor lipid control, 16.6% had not stopped smoking and 45.7% were overweight. The physical examination revealed that 13.8% of the patients had cervical bruits, 6.3% had aortic hyperpulsatility and 8.5% were lacking lower limb pulses, not previously diagnosed. It was found that in almost half of the participating patients diagnostic vascular guidelines were not being followed. CONCLUSION: This study shows a high prevalence of inadequate primary and secondary prevention and under-use of diagnostic vascular guidelines in the care of high-risk patients (older than 50 years with diabetes, smokers, etc.). Considerable efforts are required to effectively implement risk factor modification strategies and, with regard to Angiology Care Units, to correctly search for occult atherosclerotic lesions in high-risk patients.

Spontaneous recanalization of internal carotid artery occlusion evaluated with color flow imaging and contrast arteriography.

AIM: In strokes of embolic origin a partial recanalization of the intracranial occluded vessel occurs with a high incidence (as high as 80%). In the literature, we find few cases of revascularization, detected with color flow imaging (CFI) or with arteriography (AGF), at carotid siphon or at the origin of an occluded internal carotid artery (ICA). Up to now there have been no reliable data on the incidence and clinical consequences of SR of an extracranial ICA occlusion. In this case-report we document 8 cases of SR of occluded ICA observed in the last 10 years in our Care Unit. METHODS: We observed 8 complete ICA occlusion at the origin, detected with CFI (8 of 8) and with AGF (7 of 8). All symptomatic patients and 2 of 5 asymptomatic patients underwent CT scan in the acute phase of stroke. All patients underwent CFI follow-up (every 6-12 monhts) to evaluate contralateral CCA and ICA and the presence of new focal neurological symptoms. All patients assumed BMT (antiplatelet or anticoagulant therapy). RESULTS: SR occurred in 6 patients between 24 and 96 months, in 1 patient within 8 months and 1 patient within 6 months from the diagnosis of ICA occlusion. Diagnosis of SR was based in all patients with CFI and in 4 patients confirmed with AGF. Five patients underwent CT scan that excluded haemorrhagic transformation of previous ischemic areas or new ischemic events (2 patients did CT scan only after SR). All patients underwent CFI follow-up in a 3-88 months period. There were no new focal neurological symptoms in 7 of 8 patients, 1 patient presented aspecific neurological symptoms. CONCLUSION: Diagnosing SR of occluded extracranical ICA seems to be more frequent than expected. SR is an event that has to be researched in follow-up of these patients; besides, it seems to have a relatively benign outcome with respect to the onset of new neurological symptoms.

Takayasu arteritis in a 66-year-old caucasian woman.

A 66 year-old Italian woman was admitted to the hospital for fatigue, malaise and fever. Radial pulses were absent. She underwent echo color Doppler examination and angiography, which pointed out tight stenosis of bilateral axillary arteries; particularly, the echo color Doppler showed diffuse arterial wall thickening in the left common carotid artery (1.7 mm). Clinical features and instrumental findings suggested active Takayasu is arteritis. Corticosteroid therapy was administered and bilateral radial pulse appeared again after two months of steroid therapy. This case demonstrates the presence of Takayasu's arteritis in Western Europe and showed how the disease onset can be observed also in geriatric patients.

The value of ultrasound screening for proximal vein thrombosis after total hip arthroplasty--a prospective cohort study.

The role of ultrasound screening for proximal deep-vein thrombosis (DVT) following major hip surgery is controversial. 202 consecutive patients, who had received warfarin prophylaxis after total hip arthroplasty underwent a bilateral ultrasound assessment of the proximal vein system (using the criterion of vein compressibility) before hospital discharge. In the 9 patients (4.5%; 95% CI, 2.1-8.3%) with positive test anticoagulant treatment was successfully continued for three months. In all the remaining 193 patients the warfarin treatment was withdrawn. A second ultrasound test was performed 15 days later, and showed a new (asymptomatic) abnormality compatible with proximal DVT in 2 patients (1.0%; 95% CI, 0.1-3.7%). All other 191 patients remained asymptomatic until the completion of a 3-month follow-up period (rate of symptomatic thromboembolism, 0/191, 0%; 95% CI, 0-1.9%). Because of the relatively high incidence of proximal DVT in patients undergoing major orthopaedic surgery under warfarin prophylaxis, screening for proximal DVT at hospital discharge in these patients is indicated. The negativity of this test has the potential of safely preventing the extension of anticoagulation beyond hospital stay. A larger controlled study in which the value of this strategy is tested against the prolongation of oral anticoagulation in patients with a negative ultrasound screening at discharge is indicated.

Renal involvement in subjects with peripheral atherosclerosis.

BACKGROUND: Ischemic nephropathy is an important cause of renal failure in western countries. Subclinical renal function abnormalities may exist in patients with extrarenal atherosclerosis, and may precede the onset of overt ischemic nephropathy. METHODS: To assess the impact of extrarenal atherosclerosis on the kidney, we evaluated renal function in 89 subjects with differing degrees of peripheral atherosclerosis, without manifest clinical or laboratory signs of ischemic nephropathy and renovascular hypertension. All laboratory testing, ultrasonography with Doppler analysis for the localization of peripheral vascular disease (carotid and lower limb arteries), and non-invasive evaluation of renal function by radionuclide studies of renal plasma flow (MAG3 clearance) and glomerular filtration (DTPA clearance), as well as total, LDL and HDL cholesterol, and triglycerides were determined; smoking habit was recorded. By combining sonographic data on arterial tree stenosis (ATS), the subjects were grouped according to the atherosclerotic vascular damage (ATS involvement). RESULTS: Despite no change in plasma creatinine and DTPA clearance (from 91.58+/-26.53 mL/min/1.73 m2 to 93.47+/-24.82), MAG3 clearance progressively declined with the severity of vascular damage (from 244.86+/-60.60 mL/min/1.73 m2 to 173.59+/-58.74). Stepwise multiple regression analysis indicated that MAG3 clearance was best explained by ATS involvement (standardized beta coefficient -0.40; p<0.001), smoking habit (-0.34; p= 0.004), and serum LDL-cholesterol (-0.24; p<0.035). CONCLUSIONS: The renal hemodynamic profile in atherosclerotic patients might constitute functional evidence of the silent phase of ischemic renal disease. The findings suggest that renal function should be carefully assessed in patients with extrarenal atherosclerosis, particularly in those with classic cardiovascular risk factors.

Clinical outcome of patients with internal carotid artery occlusion: a prospective follow-up study.

PURPOSE: We prospectively evaluated whether, and to what extent, different clinical presentations (symptomatic or asymptomatic) or the presence of atherosclerotic narrowing of the contralateral carotid system modifies the mortality rate and the incidence of nonfatal cerebrovascular events in patients with internal carotid artery (ICA) occlusion. METHODS: A prospective cohort study was conducted in the Unit Care of Angiology at the University Hospital of Padua in Italy. Consecutive patients with ICA occlusion were eligible for the study. Between 1990 and 1991, 41 such patients were identified at our center. All patients were observed prospectively for a mean of 44.5 months, except for one patient who was lost to follow-up after 12 months. Patients with severe (ie, more than 75%) stenosis of the contralateral internal carotid artery were scheduled for thromboendarterectomy. ICA occlusion was objectively documented in all patients by using a combination of echo-color Doppler scanning and continuous-wave Doppler scanning (periorbital flow). RESULTS: The overall mortality rate was 22.0% (95% CI, 10.6-37.6), and the stroke-related mortality rate was 7.3% (95% CI, 1.5-19.9). No differences in overall and stroke-related mortality rates were observed between asymptomatic and symptomatic patients. None of the patients experienced nonfatal cerebrovascular events. CONCLUSION: ICA occlusion seems to represent a relatively benign condition, in both its symptomatic and asymptomatic presentation. The presence of an atherosclerotic stenosis less than 75% of the contralateral ICA does not seem to worsen the prognosis of this condition.

[Superficial thrombophlebitis]. / Tromboflebiti superficiali.

Thrombophlebitis of the superficial veins (SVT) of the leg is usually regarded as a mild and uncomplicated disease. Although this is generally true for acute thrombosis of the branches of the saphenous vein, the natural history of SVT involving the main trunk may not be as benign. The association of SVT with deep venous thrombosis (DVT) has been reported to range from 17 to 40%; the progression of the thrombotic process from the greater saphenous vein into the deep venous system has been reported in 8.6% of the cases. For this reason, even if symptoms of DVT are lacking, it is necessary to use duplex ultrasonography to be certain that DVT does not exist concurrently with SVT. In a recent study we found that saphenous-vein thrombi embolize even when no femoral-vein involvement is evident. Of 21 patients included in the study, findings compatible with a high probability of pulmonary embolism were detected in 7 (33.3%, 95% CI, 14.6 to 57.0), although clinical symptoms were present only in 1. The risk of pulmonary embolism is similarly high in patients with and without thrombosis at the sapheno-femoral junction. These patients presumably would benefit from anticoagulation, but such a benefit remains to be proven. Superficial thrombophlebitis, in the absence of DVT proven by duplex ultrasonography, is generally treated with nonsteroidal anti-inflammatory agents. A prospective randomized study is being carried out at our Institution evaluating therapeutic doses of anticoagulant drugs in SVT. Interim report suggests that, in thrombophlebitis of the thigh, high fixed doses of unfractioned heparin are more effective than low doses for the prevention of early and late venous thromboembolic complications and are not associated with an appreciable bleeding risk.

Rare complications during surgical vein cannulation in extremely low birthweight neonates.

Extremely low birthweight neonates often require total parenteral nutrition by central venous catheterization.The technique of choice is the percutaneous cannulation via the basilica or cephalic vein; in particular cases, these peculiar patients need a cut down catheterization. This paper describes some unusual complications of this surgical approach.

An unexpectedly high rate of pulmonary embolism in patients with superficial thrombophlebitis of the thigh.

PURPOSE: The rate of objectively proven pulmonary embolism in patients with thrombophlebitis of the greater saphenous vein was studied. METHODS: Consecutive ambulant patients with thrombophlebitis of the greater saphenous vein, involving the above-knee segment, underwent a complete venous echo color Doppler examination of the lower limbs, perfusion lung scanning, and chest radiography. A high probability of pulmonary embolism was defined as the presence of two or more large segmental defects, one large and two or more moderate perfusion defects, or four or more moderate perfusion defects, with no corresponding abnormality found by means of chest radiography. RESULTS: Of the 21 patients included in the study, findings compatible with a high probability of pulmonary embolism were detected in seven patients (33.3%; 95% CI, 14.6 to 57. 0), although clinical symptoms of pulmonary embolism were present only in one patient. No association was found between the presence of thrombosis at the saphenofemoral junction and the risk for pulmonary embolism. CONCLUSION: The rate of pulmonary embolism in patients with thrombophlebitis of the greater saphenous vein is unexpectedly high. This risk is similarly high in patients with thrombosis at the saphenofemoral junction and in patients without thrombosis at the saphenofemoral junction. Our results are consistent with those of other recent investigations and suggest that superficial thrombophlebitis of the thigh is not as benign a disease entity as previously described.

D-dimer testing as an adjunct to ultrasonography in patients with clinically suspected deep vein thrombosis: prospective cohort study. The Multicentre Italian D-dimer Ultrasound Study Investigators Group.

OBJECTIVE: To investigate the efficacy of using a rapid plasma D-dimer test as an adjunct to compression ultrasound for diagnosing clinically suspected deep vein thrombosis. DESIGN: D-dimer concentrations were determined in all patients with a normal ultrasonogram at presentation. Repeat ultrasonography was performed 1 week later only in patients with abnormal D-dimer test results. MAIN OUTCOME AND MEASURES: Patients with normal ultrasonograms were not treated with anticoagulants and were followed for 3 months for thromboembolic complications. SETTING: University research and affiliated centres. SUBJECTS: 946 patients with clinically suspected deep vein thrombosis. RESULTS: Ultrasonograms were abnormal at presentation in 260 (27.5%) patients. Of the remaining 686 patients tested for D-dimer, 88 (12.8%) had abnormal concentrations. During follow up venous thromboembolic complications occurred in one of the 598 patients who were not treated with anticoagulants and who had an initial normal ultrasonogram and D-dimer concentration, whereas thromboembolic complications occurred in two of the 83 untreated patients who had abnormal D-dimer concentrations but a normal repeat ultrasonogram. The cumulative incidence of venous thromboembolic complications during follow up was 0.4% (95% confidence interval 0% to 0.9%). The rapid plasma D-dimer test used as an adjunct to compression ultrasonography resulted in a reduction in the mean number of repeat ultrasound examinations and additional hospital visits from 0.7 to 0.1 per patient. CONCLUSIONS: Testing for D-dimer as an adjunct to a normal baseline ultrasound examination decreased the number of subsequent ultrasound examinations considerably without any increased risk of venous thromboembolic complications in patients not receiving anticoagulants. The use of ultrasound and testing for D-dimer enabled treatment decisions to be made at the time of presentation in most patients.

Renal impairment in chronic cigarette smokers.

To determine the effect of chronic cigarette smoking on renal function, a cross-sectional study was carried out with 30 subjects who had no known vascular disease risk factor other than cigarette smoking, and 24 age- and sex-matched controls without any vascular risk factor including cigarette smoking. Renal function by radionuclide studies of renal plasma flow, GFR, and plasma endothelin-1 concentration was determined. Compared with nonsmokers, smokers had a renal function impairment characterized by a normal GFR and a significant reduction in renal plasma flow as reflected by MAG3 clearance (199.20 +/- 58.85 ml/min per 1.73 m2 versus 256.54 +/- 60.14 ml/min per 1.73 m2; t = 3.52, P < 0.001). MAG3 clearance was significantly correlated with age and smoking. The renal dysfunction was associated with an increase in plasma endothelin-1 concentration (21.56 +/- 1.15 pmol/L versus 25.01 +/- 3.21 pmol/L; t = 5.00, P < 0.001). Former smokers as well had similar, although milder, abnormalities. In conclusion, cigarette smokers manifest an impairment of renal function, suggesting that smoke may have a detrimental effect on renal function.