Small bowel angioectasia-The clinical and cost impact of different management strategies.

BACKGROUND: The management of patients with recurrent anaemia and small bowel angioectasia (SBA) is costly and challenging. AIMS/METHODS: In this retrospective cohort study, we examined the clinical and cost implication of a combination therapy of Somatostatin analogues (SA) and endoscopic ablation, endoscopic therapy alone, and conservative management. RESULTS: Median number of bleeding episodes reduced from 3.5 (IQR 4) in the year before, to 1 (IQR 2) in the year after starting combination therapy with SA (p = 0.002). There were no differences in number of bed days (13.7 vs. 15.3, p = 0.66) and cost (£10,835 vs £11,653, p = 0.73) in the year before and after starting combination therapy. There was a trend towards a reduction in median number of blood transfusions episodes (17 vs 5, p = 0.07) and therapeutic endoscopies (1 vs. 0, p = 0.05) after starting SA. In patients suitable for endoscopic therapy alone, time spent in hospital was reduced (-3.5 days, p = 0.004), but bleeding episodes, transfusions and cost of treatment were not different. Patients requiring a combination therapy were significantly more co-morbid with a mean (± sd) Charlson comorbidity index (CCI) of 7.1 (± 2.7). Higher CCI (OR 2.1, 95% CI 1.1-3.9) and presence of chronic renal failure (OR 4.1, 95% CI 1.4-12.4) predicted escalation to combination therapy. CONCLUSIONS: SAs may be a useful adjunct to endoscopic therapy for transfusion dependent comorbid patients. In the first year they reduce bleeding episodes. Cost in the 1-year before and after adding on SA are no different suggesting additional clinical benefit can be gained without additional cost.

Avaliação das aberrações de alta ordem em pacientes com ceratocone inicial / Assessment of high-order aberrations in patients with early keratoconus

RESUMO Objetivo Identificar alterações de aberrometria de alta ordem em diferentes graus de ceratocone. Métodos Estudo transversal, retrospectivo, observacional. Foram analisados 54 pacientes (108 olhos) diagnosticados com ceratocone pelo mesmo especialista em córnea por meio dos critérios ABCD de Belin/Ambrósio Enhanced Ectasia, utilizando-se o tomógrafo Pentacam® HR 70900 (Oculus Wetzlar, Alemanha). Além disso, foram feitas análises qualitativa e quantitativa das aberrações de alta ordem desses mesmos pacientes por meio do OPD-Scan III-NIDEK. Resultados Por meio da avaliação de ambos os olhos dos pacientes com os critérios de Belin-Ambrósio, constatou-se presença de ceratocone em 34 pacientes. Ademais, por meio da análise estatística, constatou-se relação direta entre a asfericidade posterior e o desenvolvimento do ceratocone, com p<0,001 (referência: p<0,05). Por meio da análise do OPD-Scan III-NIDEK, as principais aberrações de alta ordem encontradas nos pacientes com ceratocone foram coma, trefoil e aberração esférica. Conclusão O raio da curvatura posterior é a primeira variável a se alterar com o desenvolvimento do ceratocone, o que se faz perceptível na análise da asfericidade posterior por meio o Pentacam®. Além disso, a alteração da paquimetria e da asfericidade posterior influencia diretamente o desenvolvimento de aberrações de alta ordem em pacientes com ceratocone.

ABSTRACT Objective To identify higher order aberrometry changes in different degrees of keratoconus. Methods Cross-sectional, retrospective, observational study. Fifty-four patients (108 eyes) diagnosed with keratoconus by the same corneal specialist using the Belin/Ambrósio Enhanced Ectasia ABCD criteria were analyzed, using the Pentacam® HR 70900 tomograph (Oculus Wetzlar, Germany). In addition, qualitative and quantitative analysis of higher order aberrations in these patients was performed using the OPD-Scan III-NIDEK. Results Through the evaluation of both eyes of the patients according to the criteria of Benin Ambrósio, the presence of KCN was verified in 34 patients. Furthermore, through statistical analysis, a direct relationship was found between posterior asphericity and the development of KCN; p<0.001 (reference: p<0.05). Through the analysis of the OPD scan, the main higher order aberrations found in patients with KCN were Coma, Trefoil and Spherical Aberration (AE). Conclusion The posterior curvature radius is the first variable to change with the development of the KCN, which is noticeable in the analysis of posterior asphericity in Pentacam. In addition, alterations in pachymetry and posterior asphericity directly influence the development of higher order aberrations in patients with KCN.

Endothelial Function Assessment by Flow-Mediated Dilation Method: A Valuable Tool in the Evaluation of the Cardiovascular System.

Cardiovascular diseases (CVDs) in the course of atherosclerosis are one of the most critical public health problems in the world. Endothelial cells synthesize numerous biologically active substances involved in regulating the functions of the cardiovascular system. Endothelial dysfunction is an essential element in the pathogenesis of atherosclerosis. Thus, the assessment of endothelial function in people without overt CVD allows for a more accurate estimate of the risk of developing CVD and cardiovascular events. The assessment of endothelial function is primarily used in scientific research, and to a lesser extent in clinical practice. Among the tools for assessing endothelial function, we can distinguish biochemical and physical methods, while physical methods can be divided into invasive and non-invasive methods. Flow-mediated dilation (FMD) is based on the ultrasound assessment of changes in the diameter of the brachial artery as a result of increased blood flow. FMD is a non-invasive, safe, and repeatable test, but it must be performed by qualified and experienced medical staff. The purpose of this paper is to present the literature review results on the assessment of endothelial function using the FMD method, including its methodology, applications in clinical practice and research, limitations, and future perspectives.

Assessment of main pancreatic duct cutoff with dilatation, but without visible pancreatic focal lesion on MDCT: a novel diagnostic approach for malignant stricture using a CT-based nomogram.

OBJECTIVES: To identify useful features to predict hidden pancreatic malignancies in patients with main pancreatic duct (MPD) abrupt cutoff and dilatation, but without visible focal pancreatic lesions on CT. METHODS: This retrospective study included 92 patients (mean age, 63.4 ± 10.6 years, 63 men and 29 women) with MPD abrupt cutoff and dilatation, but without visible focal pancreatic lesion on contrast-enhanced CT between 2009 and 2021. Two radiologists independently evaluated the CT imaging features. Multivariable logistic regression analysis was performed to identify clinical and CT imaging features for hidden pancreatic malignancies. A nomogram was developed based on these results and assessed its performance. RESULTS: Thirty-eight (41.3%) and 54 (58.7%) were classified into the malignant and benign groups, respectively. In the multivariable analysis, CA19-9 elevation (odds ratio [OR] 7.5, p = 0.003), duct cutoff site at the head/neck (OR 7.6, p = 0.006), parenchymal contour abnormality at the duct cutoff site (OR 13.7, p < 0.001), and presence of acute pancreatitis (OR 11.5, p = 0.005) were independent predictors of pancreatic malignancy. A combination of any two significant features showed an accuracy of 77.2%, and a combination of any three features exhibited a specificity of 100%. The CT-based nomogram showed an area under the curve (AUC) of 0.84 (95% confidence interval, 0.77-0.90). CONCLUSIONS: The three CT imaging features and CA19-9 elevation translated into a nomogram permit a reliable estimation of hidden pancreatic malignancies in patients with MPD abrupt cutoff without visible focal pancreatic lesion. It may facilitate determining whether to proceed to further diagnostic tests. KEY POINTS: • Isoattenuating pancreatic ductal adenocarcinoma can manifest only as an isolated main pancreatic duct (MPD) dilatation with abrupt cutoff, making it difficult to distinguish from benign strictures. • Along with the serum CA 19-9 elevation, MPD cutoff site at the pancreas head or neck, parenchymal contour abnormality at the duct cutoff site, and associated acute pancreatitis indicated a higher probability of the malignant MPD strictures. • The CT-based nomogram provided excellent diagnostic performance (AUC of 0.84) for hidden pancreatic malignancies in patients with MPD abrupt cutoff and dilatation.

Magnetic resonance imaging assessment of aortic dilatation and distensibility in 269 patients with repaired tetralogy of Fallot.

PURPOSE: To determine the prevalence and degree of aortic dilatation (Adilatation), severity of aortic stiffness (Astiff), factors for Adilatation, and level of aortic root most sensitive to Astiff in patients with repaired tetralogy of Fallot (rTOF). MATERIALS AND METHODS: 269 patients with rTOF (mean age 14.9 ± standard deviation 5.0 years) were analyzed for Adilatation at annulus, sinus, sinotubular junction, and ascending aorta (aAo). Aortic size index was graded as Z score < 2, 2-2.99, 3-4.99 and ≥ 5. Aortic distensibility (aAdis) was categorized according to 4 aortic levels and dilatation severity. Factors for Adilatation and level of aortic root most sensitive to Astiff were analyzed. RESULTS: Sinus and aAo were the two most common sites of Adilatation, with a prevalence of 84% and 76%, respectively. A decreased aAdis was found (mean 5.38 ± 1.79 10-3 mmHg-1). aAdis only declined significantly at the sinus level (p = 0.009). Male sex, age-at-repair and aortic regurgitation were significant factors for Adilatation, with male sex as the strongest factor (odds ratio 2.94). There was a significant decline in aAdis at sinus level (p = 0.002) as Adilatation progressed. CONCLUSIONS: We observed a high prevalence of Adilatation and Astiff in patients with rTOF. Male sex is the strongest factor for Adilatation. The sinus is the most sensitive area for determining a negative aAdis effect.

Measurement accuracy of prototype non-contrast, compressed sensing-based, respiratory motion-resolved whole heart cardiovascular magnetic resonance angiography for the assessment of thoracic aortic dilatation: comparison with computed tomography angiography.

BACKGROUND: Patients with thoracic aortic dilatation who undergo annual computed tomography angiography (CTA) are subject to repeated radiation and contrast exposure. The purpose of this study was to evaluate the feasibility of a non-contrast, respiratory motion-resolved whole-heart cardiovascular magnetic resonance angiography (CMRA) technique against reference standard CTA, for the quantitative assessment of cardiovascular anatomy and monitoring of disease progression in patients with thoracic aortic dilatation.  METHODS: Twenty-four patients (68.6 ± 9.8 years) with thoracic aortic dilatation prospectively underwent clinical CTA and research 1.5T CMRA between July 2017 and November 2018. Scans were repeated in 15 patients 1 year later. A prototype free-breathing 3D radial balanced steady-state free-precession whole-heart CMRA sequence was used in combination with compressed sensing-based reconstruction. Area, circumference, and diameter measurements were obtained at seven aortic levels by two experienced and two inexperienced readers. In addition, area and diameter measurements of the cardiac chambers, pulmonary arteries and pulmonary veins were also obtained. Agreement between the two modalities was assessed with intraclass correlation coefficient (ICC) analysis, Bland-Altman plots and scatter plots. RESULTS: Area, circumference and diameter measurements on a per-level analysis showed good or excellent agreement between CTA and CMRA (ICCs > 0.84). Means of differences on Bland-Altman plots were: area 0.0 cm2 [- 1.7; 1.6]; circumference 1.0 mm [- 10.0; 12.0], and diameter 0.6 mm [- 2.6; 3.6]. Area and diameter measurements of the left cardiac chambers showed good agreement (ICCs > 0.80), while moderate to good agreement was observed for the right chambers (all ICCs > 0.56). Similar good to excellent inter-modality agreement was shown for the pulmonary arteries and veins (ICC range 0.79-0.93), with the exception of the left lower pulmonary vein (ICC < 0.51). Inter-reader assessment demonstrated mostly good or excellent agreement for both CTA and CMRA measurements on a per-level analysis (ICCs > 0.64). Difference in maximum aortic diameter measurements at baseline vs follow up showed excellent agreement between CMRA and CTA (ICC = 0.91). CONCLUSIONS: The radial whole-heart CMRA technique combined with respiratory motion-resolved reconstruction provides comparable anatomical measurements of the thoracic aorta and cardiac structures as the reference standard CTA. It could potentially be used to diagnose and monitor patients with thoracic aortic dilatation without exposing them to radiation or contrast media.

Aortic dilatation: Value of echocardiography in the systematic assessment of elite rugby players in the French National Rugby League (LNR).

The value of echocardiography in the screening of athletes in addition to the electrocardiogram is debated and still unclear. 336 rugby players in French professional divisions (Top 14, Pro D2) were prospectively assessed with electrocardiogram and echocardiography. 75% were Caucasian, 16.4% Pacific Islanders, and 8.6% Afro-Caribbean. Six (1.8%) players had electrocardiogram abnormalities, exclusively negative T waves. Twenty-one (6.25%) of them had abnormal echocardiography findings: one possible early hypertrophic cardiomyopathy, one anomalous origin of coronary artery, two left ventricular dilatations, one isolated bicuspid aortic valve, two aortic regurgitations, and 14 ascending aortic dilatations. The median aortic diameter was modestly correlated with age: 32 mm [23-48] in players aged ≤25 years vs 33.5 mm [24-50] in those aged >25 years (P = 0.02, correlation coefficient -.01). This tendency increased with cumulative hours of weight training: 34 mm [24-50] in forwards vs 32 mm [25-44] in backs (P = 0.01); and ethnicity, with Pacific Islanders having higher values in both raw data and body surface area or height-indexed data than Afro-Caribbeans and Caucasians: 34 [25-50] vs 32 [27-48] and 33 [23-49] mm (P = 0.017); 15 [12.2-21] vs 14.8 [11-19.9] and 14.8 [10-20.9] mm/m2 (P < 0.0001); 18.5 [14-25] mm/m vs 17.4 [14.8-25] mm/m and 17.6 [12.2-25.3] mm/m (P = 0.0125). In a population of professional rugby players, echocardiography was contributive. The main anomaly was aortic dilatation (14/336, 4.2%). While this is proportionally much higher than in other sports, the cutoffs need to be defined more precisely by including the criterion of ethnicity, as is already the case for electrocardiography.

3-D assessment of gaze-induced eye shape deformations and downgaze-induced vitreous chamber volume increase in highly myopic eyes with staphyloma.

PURPOSE: To determine if the stress of normal eye movements results in gaze-induced globe deformations, vitreous chamber axial length and vitreous chamber axial volume (VCAV) change in highly myopic eyes. METHODS: A prospective imaging study was performed on 82 eyes of 43 patients with high myopia (>27 mm of axial length) with a clinical diagnosis of staphyloma. Three-dimensional MRI scans were acquired while subjects gazed in five directions (primary, nasal, temporal, superior and inferior). Surface renderings were generated, and a processing pipeline was created to automate alignment of the eye and to measure VCAV within 5.5 mm of the visual axis for each eye in every gaze. The degree of gaze-induced globe deformation was determined by calculating the Dice coefficient to assess the degree of overlap of the sclera at each eccentric gaze with that found in primary gaze. Each eccentric gaze VCAV was compared to VCAV in primary gaze using a fixed-effects regression allowing for subject-specific and eye-specific effects. RESULTS: The Dice coefficient showed significant gaze-induced eye shape changes in all gazes (all p<0.0001). There were no statistically significant gaze-induced VCAV changes when comparing primary gaze to nasal, temporal or upgaze. However, when changing from primary to downgaze, VCAV was increased by +4.79 mm3 (p=0.002, 95% CI 1.71 to 7.86). CONCLUSION: Significant gaze-induced globe deformation was noted in all gazes, but a reversible, instantaneous VCAV increase occurred only in downgaze, which is consistent with studies supporting the association of environmental factors such as near work with myopia development and progression.

Appropriateness of Abdominal Aortic Aneurysm Screening With Ultrasound: Potential Cost Savings With Guideline Adherence and Review of Prior Imaging.

OBJECTIVE: To assess the appropriateness of abdominal aortic aneurysm (AAA) screening with ultrasound (US) and potential cost savings by adhering to guidelines and reviewing prior imaging. METHODS: Screening aortic US performed in Nova Scotia from January 1 to April 30, 2019, were reviewed. Patient sex, age, risk factors, and study result (negative, <2.5 cm; ectatic, 2.5-2.9 cm; positive for AAA, ≥3 cm) were recorded. Previous imaging tests were reviewed for the presence/absence of aortic ectasia or aneurysm. Appropriateness was based on the Canadian Task Force on Preventive Health Care (CTFPHC) and the Canadian Society of Vascular Surgery (CSVS) guidelines. The number of potentially averted US, subsequent missed positive findings, and cost savings (over the 4-month period) were calculated according to: 1) each guideline; and 2) each guideline combined with review of imaging done 0 to 5 years and 0 to 10 years previously. RESULTS: There were 17 (4.6%) of 369 ectatic aortas and 18 (4.9%) of 369 AAAs. The number of potentially averted examinations, missed ectatic aortas, missed AAAs, and cost savings were as follows, respectively: CTFPHC, 222 (60.2%) of 369, 8, 7, and CAD$20 501.70; CSVS, 117 (31.7%) of 369, 4, 2, and CAD$10 804.95. The model that would yield the greatest cost savings and fewest missed positive findings was the combination of CSVS guidelines with review of prior imaging within 5 years; this would avert 189 (51.2%) of 369 examinations, save CAD$17 454.15 over 4 months, and miss only 2 AAAs and 2 ectatic aortas. CONCLUSION: Over half of aortic US screening tests can be safely averted by adhering to CSVS guidelines and reviewing imaging performed within 5 years.

Fabry disease with early-onset ventricular dilation: A case report.

RATIONALE: The most common cardiac involvement of Fabry disease (FD) is left ventricular hypertrophy (LVH), which usually occurs in male patients over the age of 30. In rare cases, it can progress to ventricular dilation in the late stage of the disease. PATIENT CONCERNS: A 16-year-old boy presenting with recurrent extremity pain and chest distress was admitted to our hospital. Imaging examinations revealed ventricular dilation. DIAGNOSIS: α-Galactosidase A enzyme assay and GLA gene sequencing confirmed the diagnosis of FD and revealed a novel mutation c.76_77insT. INTERVENTIONS: The patient was treated using metoprolol (23.75 mg qd) and angiotensin-converting enzyme inhibitor (fosinopril sodium 5 mg qd). He refused enzyme replacement therapy for financial reasons. OUTCOMES: The echocardiography, electrocardiography, renal function, and routine blood and urine tests performed 20 months after the patients discharge from hospital showed no significant changes. The patient reported a slow and gradual decrease in the frequency and degree of pain and chest distress, starting approximately 24 months after discharge. LESSONS: Cardiac involvement of FD can progress rapidly in some cases. Screening for FD should be considered in patients with unexplained ventricular dilation, especially in those with a history of typical FD manifestations.

Could the percent tissue altered (PTA) index be considered as a unique factor in ectasia risk assessment?

PURPOSE: To evaluate the efficacy, safety, predictability and stability of the percent tissue altered (PTA) formula in post-LASIK (laser-assisted in situ keratomileusis) ectasia risk assessment. METHODS: One hundred and ninety-three eyes from 104 patients with low to moderate myopia that underwent femtosecond LASIK were included in this retrospective, observational and longitudinal study. Seventy-eight eyes were classified in the higher-PTA (> 40%) group and 115 eyes in the lower-PTA (< 40%) group. Spherical manifest refraction, cylinder manifest refraction, logMAR and Snellen previous corrected distance visual acuity (CDVA), uncorrected distance visual acuity (UDVA), anterior face Baiocchi Calossi Versaci index (BCVf) and posterior face (BCVb), central corneal thickness (CCT), estimated residual stromal bed (RSB), spherical aberration (SA) and root mean square (RMS) were reported. All patients were followed up for 4 years. RESULTS: In the higher-PTA group, 97% of eyes reported UDVA 20/20 or better, and in the lower-PTA group, all eyes achieved 20/20 or better. No group reported decreased visual acuity. The higher-PTA group obtained 55% of eyes within ± 0.50 D and 90% within ± 1.00 D; and the lower-PTA group obtained 63% of eyes within ± 0.50 D and 90% within ± 1.00 D. Both groups showed a refraction correction of 0.50 D or more in 36% and 31% of eyes, in the higher-PTA and the lower-PTA groups, respectively. CONCLUSION: Percent tissue altered index should not be considered as a unique variable in post-LASIK ectasia risk assessment. Ectasia susceptibility screening should integrate tomography and biomechanical variables in order to help us to decide any refractive treatment choice and increasing refractive surgery safety.

Right ventricular assessment can improve prognostic value of Euroscore II.

BACKGROUND: The aim of this multicenter prospective study was to evaluate the prognostic weight of preoperative right ventricular assessment on early mortality in cardiac surgery. METHODS: This is a multicenter prospective observational study performed by the Italian Group of Research for Outcome in Cardiac Surgery (GIROC) including 11 centers. From October 2017 to March 2019, out of 923 patients undergoing cardiac surgery, 28 patients with some missing data were excluded and 895 patients were enrolled in the study right ventricular dilatation was defined as a basal end-diastolic diameter >42 mm. The right ventricle (RV) function was assessed using the combination of three parameters: fractional area changing (FAC), tricuspid annular plane systolic excursion (TAPSE), and S'-wave using tissue Doppler imaging (TDI-S'); RV dysfunction was defined as the presence of at least two of the following cutoffs: FAC <35%, TAPSE <17 mm, and TDI S' <9.5 mm RESULTS: Among the entire cohort, 624 (70%) showed normal RV, 92 (10%) isolated RV dilatation, 154 (17%) isolated RV dysfunction, and 25 (3%) both RV dilatation and dysfunction. Non-surviving patients showed a significantly higher rate of RV alteration at multivariable analysis, RV status was found to be an independent predictor for higher in-hospital mortality beside Euroscore II. CONCLUSIONS: This prospective multicenter observation study shows the importance to assess RV preoperatively and to include both RV function and dimension in a risk score model such as Euroscore II to implement its predictivity, since PH cannot always mirror the status of the right ventricle.

Assessment of the Relationship Between C-Reactive Protein-to-Albumin Ratio and the Presence and Severity of Isolated Coronary Artery Ectasia.

We investigated the relationship between C-reactive protein-to-albumin ratio (CAR) and coronary artery ectasia (CAE). The retrospective study population included 150 patients with isolated CAE, 150 with obstructive coronary artery disease (CAD), and 150 with a normal coronary artery angiogram (NCA). The severity of isolated CAE was determined according to the Markis classification. C-reactive protein-to-albumin ratio was significantly higher in patients with isolated CAE than in those with obstructive CAD and NCA (10.5 [5.9-30.9], 5.7 [1.8-13.2] and 3.0 [0.9-8.9], respectively). Logistic regression analysis showed that CAR (odds ratio [OR]: 3.054, 95% CI: 1.021-9.165, P = .001), platelet-to-lymphocyte ratio (PLR; OR: 1.330, 95% CI: 1.025-1.694, P = .044), and monocyte-to-high density cholesterol ratio (MHR; OR: 1.031, 95% CI: 1.009-1.054, P = .006) were independently associated with the presence of isolated CAE. Receiver operating characteristic curve analysis showed that CAR (area under the curve [AUC] ± standard error [SE] = 0.838 ± 0.016; P < .001) had a stronger diagnostic value for detecting significant CAE than PLR (AUC ± SE = 0.632 ± 0.023) and MHR (AUC ± SE = 0.726 ± 0.022). C-reactive protein-to-albumin ratio had a significantly strong correlation with the severity of isolated CAE (r = 0.536, P < .001). To the best of our knowledge, this study showed for the first time that CAR was significantly associated with CAE presence and severity.

Conventional and new electrocardiographic criteria for hypertension-mediated cardiac organ damage: A narrative review.

Hypertension-mediated organ damage (HMOD) is frequently observed in hypertensive patients at different cardiovascular (CV) risk profile. This may have both diagnostic and therapeutic implications for the choice of the most appropriate therapies. Among different markers of HMOD, the most frequent functional and structural adaptations can be observed at cardiac level, including left ventricular hypertrophy (LVH), diastolic dysfunction, aortic root dilatation, and left atrial enlargement. In particular, LVH was shown to be a strong and independent risk factor for major CV events, namely myocardial infarction, stroke, congestive heart failure, CV death. Thus, early identification of LVH is a key element for preventing CV events in hypertension. Although echocardiographic assessment of LVH represents the gold standard technique, this is not cost-effective and cannot be adopted in routine clinical practice of hypertension. On the other hand, electrocardiographic (ECG) assessment of HMOD relative to the heart is a simple, reproducible, widely available and cost-effective method to assess the presence of LVH, and could be preferred in large scale screening tests. Several new indicators have been proposed and tested in observational studies and clinical trials of hypertension, in order to improve the relatively low sensitivity of the conventional ECG criteria for LVH, despite high specificity. This article reviews the differences in the use of the main conventional and the new 12 lead ECG criteria of LVH for early assessment of asymptomatic, subclinical cardiac HMOD in a setting of clinical practice of hypertension.

Expert consensus and evidence-based recommendations for the assessment of flow-mediated dilation in humans.

Endothelial dysfunction is involved in the development of atherosclerosis, which precedes asymptomatic structural vascular alterations as well as clinical manifestations of cardiovascular disease (CVD). Endothelial function can be assessed non-invasively using the flow-mediated dilation (FMD) technique. Flow-mediated dilation represents an endothelium-dependent, largely nitric oxide (NO)-mediated dilatation of conduit arteries in response to an imposed increase in blood flow and shear stress. Flow-mediated dilation is affected by cardiovascular (CV) risk factors, relates to coronary artery endothelial function, and independently predicts CVD outcome. Accordingly, FMD is a tool for examining the pathophysiology of CVD and possibly identifying subjects at increased risk for future CV events. Moreover, it has merit in examining the acute and long-term impact of physiological and pharmacological interventions in humans. Despite concerns about its reproducibility, the available evidence shows that highly reliable FMD measurements can be achieved when specialized laboratories follow standardized protocols. For this purpose, updated expert consensus guidelines for the performance of FMD are presented, which are based on critical appraisal of novel technical approaches, development of analysis software, and studies exploring the physiological principles underlying the technique. Uniformity in FMD performance will (i) improve comparability between studies, (ii) contribute to construction of reference values, and (iii) offer an easy accessible and early marker of atherosclerosis that could complement clinical symptoms of structural arterial disease and facilitate early diagnosis and prediction of CVD outcomes.

Usefulness of imaging techniques in the management of giant cell arteritis. / Utilidad de las técnicas de imagen en la valoración de la arteritis de células gigantes.

Imaging has become an essential tool in the management of patients with giant cell arteritis. Cranial involvement detected by Doppler ultrasonography is an unquestionable diagnostic finding. Imaging of the aorta and its branches with positron emission tomography, computed tomography angiography or magnetic resonance imaging may also have a role in diagnosis and in the assessment of disease activity and response to treatment, but standardisation and validation are still needed before their widespread use as an outcome measure. Aortic structural damage is associated with increased mortality in giant cell arteritis; therefore, periodic screening is recommended.

Venous leg symptoms in patients with varicocele: A multicenter assessment study (VEIN-TURKEY study).

OBJECTIVE: The aim of this study is to evaluate chronic venous disease symptoms by using the Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Symptoms (VEINES-QoL/Sym) questionnaire in varicocele patients. MATERIAL AND METHODS: The study was designed as a prospective, case controlled study and conducted in four hospitals from Turkey. A total of 600 patients who admitted to urology outpatient clinic were enrolled to the study. After the exclusion of 44 patients who do not match the inclusion criteria, the remaining 556 patients were examined for the presence and grade of varicocele and subsequently examined clinically for the presence of chronic venous disease findings. Finally, patients were asked to answer the VEINES-Sym questionnaire consisting of 10 items. All patients' demographic parameters, cardiovascular risk factors, other co-morbid diseases and drug usage were noted. RESULTS: Patients were classified into two groups: varicocele (+) group ( n = 269) and varicocele (-) group ( n = 287). VEINES-Sym scores of varicocele patients were lower compared to patients without varicocele (41.41 ± 5.21, 43.19 ± 3.22, respectively, p < 0.001). Grades of varicocele significantly but inversely correlated with VEINES-Sym score ( r = 0, -206, p = 0.001). Logistic regression analysis revealed that presence of varicocele irrespective of grading significantly and independently associated with the presence of aching (odds ratio: 2.054, 95% confidence interval: 1.265-3.338, p = 0.004) and throbbing (odds ratio: 2.586, 95% confidence interval: 1.353-4.943, p = 0.004). CONCLUSION: Varicocele patients have lower VEINES-Sym scores compared to patients without varicocele and this finding is inversely correlated with the degree of the varicocele. This association supports the hypothesis that there may be a systemic vessel wall abnormality in venous disease patients. Patients with symptoms related to vascular dilatation in any territory may deserve to be assessed systematically with the support of further clinical studies.

Assessment of Duodenal Diverticula: Computed Tomography Findings.

AIMS: To demonstrate the prevalence, accompanying pathologies, imaging and follow up findings of Duodenal Diverticula (DD) with Multidetector Computed Tomography (MDCT). MATERIALS AND METHODS: Consecutive 2910 abdominal MDCTs were retrospectively reviewed on axial, coronal and sagittal planes. DD were evaluated for prevalence, location, number, size, contents, diverticular neck, accompanying pancreaticobiliary pathologies, jejunal and colonic diverticula, respectively. RESULTS: DD were diagnosed in 157 cases (5.4%) and found mostly in the second part of the duodenum. Juxta-ampullary DD was the most common type (78.3%) and mostly located ventral (n:86, 69.9%) to the ampulla of Vater. DD was solitary in 123 patients (78.3%) and more than one in 34 patients (21.7%). The median diameter of DD was 2.5 cm (range 1.5-3.6 cm) in the long-axis. The lumen of DD contains air and contrast agent (n:96, 61.1%); air, contrast agent and debris (n:42, 26.7%) in most cases. Colonic diverticula (n:36, 22.9%), cholelithiasis (n:32, 20.4%), choledocholithiasis (n:7, 4.4%), and biliary dilatation (n:8, 5.1%) were the most common additional findings. Median follow-up time was 23 months (range 11 to 41 months). In three cases, new findings (cholelithiasis, n:3, choledocholithiasis, n:1) were detected. CONCLUSION: Accompanying pathologies with DD diagnosis are valuable for physicians in order to manage the patients. Following clinical and radiological features of well-diagnosed DD might reduce the possible complications.