Cardiovascular complications and drug prescriptions in subjects with and without diabetes in a Northern region of Italy, in 2002 and 2012.

BACKGROUND AND AIMS: In contrast to the well-documented global prevalence of diabetes, much less is known about the epidemiology of cardiovascular (CV) complications in recent years. We describe the incidence of major CV events, deaths and drug prescribing patterns from 2002 to 2012 in subjects with (DM) or without diabetes mellitus (No DM). METHODS AND RESULTS: Subjects and outcomes were identified using linkable health administrative databases of Lombardy, a region in Northern Italy. A logistic regression model was used to compare myocardial infarction (MI), stroke, major amputation and death between DM and No DM in 2002 and 2012 and between the two index years in each population. The interaction between years and diabetes was introduced in the model. From 2002 to 2012 the incidence of major CV complications and death fell in both groups with a larger reduction among DM only for CV events: OR (95% CI) for the interaction 0.86 (0.79-0.93) for MI, 0.89 (0.82-0.96) for stroke, 0.78 (0.57-1.06) for major amputations. CV prevention drugs rose considerably from 2002 to 2012 particularly in DM and a switch towards safer antihyperglycemic drugs was also observed. CONCLUSIONS: Major CV complications and death declined from 2002 to 2012 in both DM and No DM. This might be due to a larger increase in prescriptions of CV drugs in DM and a relevant change toward recommended antihyperglycemic drugs.

Elevated risk of death and major cardiovascular events in subjects with newly diagnosed diabetes: findings from an administrative database.

AIMS: To investigate the incidence of major cardiovascular complications and mortality in the first years of follow-up in patients with newly diagnosed diabetes. METHODS AND RESULTS: We examined incidence rates of hospitalization for cardiovascular reasons and death among new patients with diabetes using the administrative health database of the nine million inhabitants of Lombardy followed from 2002 to 2007. Age and sex-adjusted rates were calculated and hazard ratios (HR) were estimated with a matched population without diabetes of the same sex, age (± 1 year) and general practitioner. There were 158,426 patients with newly diagnosed diabetes and 314,115 subjects without diabetes. Mean follow-up was 33.0 months (SD ± 17.5). 9.7% of patients with diabetes were hospitalized for cardiovascular events vs. 5.4% of subjects without diabetes; mortality rate was higher in patients with diabetes (7.7% vs. 4.4%). The estimated probability of hospitalization during the follow up was higher in patients with diabetes than in subjects without for coronary heart disease (HR 1.4, 95% CI 1.3-1.4), cerebrovascular disease (HR 1.3.95% CI 1.2-1.3), heart failure (HR 1.4, 95% CI 1.3-1.4) as was mortality (HR 1.4, 95% CI 1.4-1.4). Younger patients with diabetes had a risk of death or hospital admission for cardio-cerebrovascular events similar to subjects without diabetes ten years older. CONCLUSIONS: The elevated morbidity and mortality risks were clear since the onset of diabetes and rose over time. These data highlight the importance of prompt and comprehensive patients care in addition to anti-diabetic therapy in patients with newly diagnosed diabetes.

Evaluación de la hoja de información al paciente y del consentimiento informado en ensayos clínicos / Evaluation of the written informed consent form in clinical trials

Objetivo. Evaluar la calidad del contenido de la hoja de información al paciente (HIP) y del consentimiento informado (CI) en los ensayos clínicos. Material y métodos. Estudio observacional retrospectivo. Se evaluaron 50 HIP de ensayos clínicos iniciados entre 2010 y 2011. La calidad de las hojas de información fue evaluada a través de las Guías de Buena Práctica Clínica presentes en la CPMP/ICH/135/95 de la Agencia Europea de Medicamentos. Se aplicaron índices de legibilidad a las HIP y al CI. Resultados. El 10% de las HIP presentaban correctos todos los apartados; 5 fueron correctos en todas: el ensayo supone una investigación, objetivos del ensayo, participación voluntaria, personal del estudio con acceso al historial médico y confidencialidad de los datos del paciente. Los apartados menos presentes fueron responsabilidades del sujeto y alternativas disponibles. Las 50 hojas analizadas requirieron una media de 4,24 (DE = 1,87) modificaciones para su autorización por parte del Comité Ético de Investigación Clínica (CEIC). Las HIP y el CI presentaron buenos resultados en los índices de legibilidad, siendo considerados con legibilidad aceptable en el 98% de los casos. Conclusiones. El grado de cumplimiento de los diferentes aspectos que se han de reflejar en las HIP es alto. Sin embargo, las responsabilidades del sujeto y las posibles alternativas al ensayo clínico son puntos de mejora. La complejidad de lectura de las HIP y del CI es adecuada para la población media. La revisión de la HIP por parte del CEIC garantiza a los pacientes el acceso a una información completa y adecuada(AU)

Purpose. To assess the quality of the written informed consent form (WICF) in clinical trials. Material and methods. Retrospective observational study was performed on 50 WICF of clinical trials started between 2010 and 2011. The quality of the content of the WICF was assessed using the “Guideline for Good Clinical Practice” contained in the CPMP/ICH/135/95 of the European Medicines Agency. Legibility indexes were applied to the WICF. Results. The WICF was correct in all aspects in 10% of the clinical trial; five sections were correct in all WICF: “trial involves research”, “trials goals”, “participation is voluntary and the subject may withdraw at any time without penalty”, “study personnel with access to medical records” and “documents that identify the patient are confidential”. Aspects less present were “the subject's responsibilities” and “available alternatives”. All WICF required clarification by the Ethics Committee (EC), with a mean of 4.24 (SD = 1.87) changes per WICF. The WICF showed good results in the indices of readability. Almost all (98%) of WICF were considered with an acceptable readability. Conclusions. Compliance with different aspects that must appear in the WICF is high. Aspects to improve are the subject's responsibilities and available alternatives to the clinical trial. The complexity of reading the WICF is suitable for the average population. The review of the WICF by the EC guarantees the access to comprehensive and appropriate information(AU)

[Evaluation of the written informed consent form in clinical trials]. / Evaluación de la hoja de información al paciente y del consentimiento informado en ensayos clínicos.

PURPOSE: To assess the quality of the written informed consent form (WICF) in clinical trials. MATERIAL AND METHODS: Retrospective observational study was performed on 50 WICF of clinical trials started between 2010 and 2011. The quality of the content of the WICF was assessed using the "Guideline for Good Clinical Practice" contained in the CPMP/ICH/135/95 of the European Medicines Agency. Legibility indexes were applied to the WICF. RESULTS: The WICF was correct in all aspects in 10% of the clinical trial; five sections were correct in all WICF: "trial involves research", "trials goals", "participation is voluntary and the subject may withdraw at any time without penalty", "study personnel with access to medical records" and "documents that identify the patient are confidential". Aspects less present were "the subject's responsibilities" and "available alternatives". All WICF required clarification by the Ethics Committee (EC), with a mean of 4.24 (SD=1.87) changes per WICF. The WICF showed good results in the indices of readability. Almost all (98%) of WICF were considered with an acceptable readability. CONCLUSIONS: Compliance with different aspects that must appear in the WICF is high. Aspects to improve are the subject's responsibilities and available alternatives to the clinical trial. The complexity of reading the WICF is suitable for the average population. The review of the WICF by the EC guarantees the access to comprehensive and appropriate information.

Prevalence, incidence and mortality of diagnosed diabetes: evidence from an Italian population-based study.

AIMS: To describe trends in diagnosed diabetes prevalence, incidence and mortality from 2000 to 2007 in the most heavily populated Italian region. METHODS: We examined the prevalence and incidence rates of Type 1 and Type 2 diabetes and yearly mortality rates among individuals with diabetes from 2000 to 2007 using an administrative health database of prescription, disease-specific exemption and hospitalization records of more than 9 million inhabitants of Lombardy. Age- and sex-specific rates were calculated and temporal trends for subjects aged ≥ 30 years were analysed. RESULTS: The crude point diabetes prevalence rose from 3.0% in 2000 to 4.2% in 2007, a 40% increase. The incidence remained stable during the study period with a rate of 4/1000 per year. Overall mortality declined from 43.2/1000 in 2001 to 40.3/1000 in 2007 (6.7% decrease) at a rate slightly higher than that of the general population (4.8% decrease). Our projection in subjects aged ≥ 30 years indicates that the prevalence will rise continuously over the next years, reaching 11.1% in 2030. CONCLUSIONS: The prevalence of diabetes increased substantially between 2000 and 2007, mainly because there are more patients with a new diagnosis each year than those who die. The increase observed by 2007 almost reached the World Health Organization prediction for 2030. Our analyses suggest that the increase will continue over the next few decades. These data are important for defining the burden of diabetes in the near future, to help in planning health services and ensure proper allocation of resources.

Progression of reflux patterns in saphenous veins of women with chronic venous valvular insufficiency.

BACKGROUND: Venous ultrasonography identifies reflux patterns of the great and small saphenous veins (GSV, SSV), allowing evaluation of lower extremities for treatment planning and patient follow-up. OBJECTIVE: To determine progression of saphenous vein reflux patterns in women with primary venous valvular insufficiency. METHODS: Venous ultrasonography was performed in the extremities of 92 women, 43 ± 12 (23-77) years old, CEAP (clinical, aetiological, anatomical and pathological elements) clinical classes C1-C2. Two examinations were performed 33 ± 19 (8-89) months apart in patients without saphenous vein treatment. GSV and SSV reflux patterns were classified as segmental, multisegmental, distal, proximal, diffuse and normal. Prevalence was determined for each examination, separately for right and left extremities, and jointly. Prevalence was compared using χ2 statistics. RESULTS: Reflux prevalence was higher for the GSV, 89% (164/184) and 88% (n = 162), than for the SSV, 24% (n = 45) and 30% (n = 56), respectively for first and second examinations (P < 0.001). Reflux pattern prevalence was not significantly different in the right and left extremities (1.0 > P > 0.14). Most prevalent patterns were (a) GSV segmental reflux initially, 41% (76/184), decreasing to 28% (52/184) (P = 0.009), and (b) GSV multisegmental reflux at the second examination, increasing from 26% (48/184) to 40% (73/184) (P = 0.006). Prevalence of other GSV or SSV reflux patterns did not change significantly (0.88 > P > 0.19). CONCLUSIONS: We documented early findings and venous reflux progression in a specific population of women with varicose veins, reticular veins and telangiectasias. GSV segmental reflux was most prevalent initially, progressing to GSV multisegmental reflux.

Attention deficit induced by blockade of N-methyl D-aspartate receptors in the prefrontal cortex is associated with enhanced glutamate release and cAMP response element binding protein phosphorylation: role of metabotropic glutamate receptors 2/3.

The hypothesis that attention deficits induced by the hypofunction of N-methyl d-aspartate (NMDA) receptors in the prefrontal cortex (PFC) might be associated with increased glutamate release and changes in the phosphorylation of the cyclic adenosine monophosphate response element-binding protein on serine 133 (p-S(133)CREB) was investigated in this study. Infusion of 50 ng/side 3-(R)-2-carboxypiperazin-4-propyl-1-phosphonic acid ((R)-CPP), a competitive glutamate NMDA receptor antagonist, into the medial prefrontal cortex (mPFC) of rats performing the five-choice serial reaction time (5-CSRT) task, reduced accuracy of visual discrimination (measured by % correct responses) and enhanced impulsivity (measured by the number of premature responses) and compulsivity (measured by the number of perseverative responses). The mGluR2/3 receptor agonist, LY379268, injected s.c. at 0.1 mg/kg, reduced (R)-CPP-induced impairment in attentional functioning (accuracy) and impulsivity but not compulsive perseveration. In parallel studies using microdialysis technique and Western blot analysis we found that (R)-CPP (100 µM) infused in the medial prefrontal cortex increased glutamate efflux whereas injected in the medial prefrontal cortex at a dose causing impairments in attentional performance (50 ng/side) increased p-S(133)CREB in the frontal cortex (FC), decreased it in the caudate-putamen (CPu) and was without effect in the nucleus accumbens (NAC). LY379268 at the dose effective in reducing (R)-CPP-induced behavioral deficit reduced both the (R)-CPP-induced rise in glutamate efflux in the prefrontal cortex and the increase in p-S(133)CREB in the frontal cortex but was without effect on the decrease in p-S(133)CREB in the caudate-putamen. The data provide evidence that enhanced glutamate release and phosphorylation of cAMP response element binding protein (CREB) on serine 133 may be associated to attention deficit and loss of impulse control. Furthermore they suggest that mGluR2/3 agonists have a therapeutic potential for cognitive deficits.

[Pharmaceutical care self-assessment process for hospitalized patients through the Valor program]. / Autoevaluación del proceso de atención farmacéutica en pacientes hospitalizados a través del programa Valor.

OBJECTIVE: To assess the quality of pharmaceutical care for inpatients using qualitative criteria as established in the Valor program. METHOD: Evaluation study through 43 explicit structural, process, and outcome criteria within the Valor program, in which pharmacists in the Unit Dose Functional Unit may assess themselves along a compliance scale from 0 to 100%. This Unit provides daily individualized pharmaceutical care to 550 patients in an adult general and surgery hospital. Mean scores per pharmacist and item are estimated for the 2003-2005 period. RESULTS: Mean compliance assessments for all 14 interannual "structural items" were 53, 57, and 64%; those for all 13 "process items" were 52, 51, and 46%; and those for all 15 "outcome items" were 18, 28, and 26%. A variability of 20% was documented for structure and process evaluations, and of 50% for outcome assessments. CONCLUSIONS: Every autoevaluation raises to the equipment the necessity to establish improvements and to enhance communication, and the application of standardized procedures in the pharmaceutical care process.

Autoevaluación del proceso de atención farmacéutica en pacientes hospitalizados a través del programa Valor / No disponible

Objetivo: Evaluar la calidad en la atención farmacéutica alpaciente hospitalizado a través de criterios cualitativos establecidosen el programa Valor®.Método: Estudio de evaluación a través de 43 criterios explícitosestructurales, de proceso y de resultado incluidos en el programaValor® que valoran los propios farmacéuticos de la unidad funcionalde dosis unitarias, en una escala de cumplimiento del 0 a100%. Dicha unidad proporciona atención farmacéutica individualizadadiariamente a 550 pacientes, pertenecientes a un hospitalgeneral de patología y cirugía del adulto. Se calculan las mediasde las puntuaciones por farmacéutico y por elemento en el periodo2003-2005.Resultados: Las valoraciones medias de cumplimiento paralos catorce elementos estructurales interanuales fueron de 53, 57y 64%; los trece de proceso 52, 51 y 46%; y los quince de resultado18, 28 y 26%. Se evidencia una variabilidad entorno al 20%para las evaluaciones de estructura y proceso y del 50% en las deresultado.Conclusiones: Cada autoevaluación plantea al equipo farmacéuticoestablecer mejoras y potenciar la comunicación y la aplicaciónde procedimientos normalizados para el proceso de atenciónfarmacéutica

Objective: To assess the quality of pharmaceutical care forinpatients using qualitative criteria as established in the Valor®program.Method: Evaluation study through 43 explicit structural,process, and outcome criteria within the Valor® program, in whichpharmacists in the Unit Dose Functional Unit may assess themselvesalong a compliance scale from 0 to 100%. This Unit providesdaily individualized pharmaceutical care to 550 patients inan adult general and surgery hospital. Mean scores per pharmacistand item are estimated for the 2003-2005 period.Results: Mean compliance assessments for all 14 interannual“structural items” were 53, 57, and 64%; those for all 13“process items” were 52, 51, and 46%; and those for all 15 “outcomeitems” were 18, 28, and 26%. A variability of 20% wasdocumented for structure and process evaluations, and of 50% foroutcome assessments.Conclusions: Every autoevaluation raises to the equipmentthe necessity to establish improvements and to enhace communication,and the application of standardized procedures in thepharmaceutical care process

[Wasting syndrome in cancer patients: pathophysiology, clinical manifestations and drug therapy]. / El síndrome caquéctico en el paciente oncológico: fisiopatología, manifestaciones clínicas y tratamiento farmacológico.

Wasting is a syndrome related to patient functional impairment that characterizes many conditions, including cancer. The development of wasting includes changes in the metabolism, as well as in hormones and other cell mediators, which trigger a syndrome that cannot be solved by forced nutrient ingestion. The goal of this study is to review the pathophysiological components of wasting, as well as its clinical manifestations and the available specific drug therapy options for the treatment of this condition. To this end, a review of papers published during the last four years has been carried out. The treatment of wasting with drugs includes a number of combination therapies for the underlying condition, nutritional support administration, and specific drug therapy for the wasting clinical picture. Currently, the clinical efficacy of cyproheptadine, hydrazine and pentoxyfilline in the treatment of anorexia is uncertain. Only progestagen derivatives have shown to increase appetite and food intake, and to improve nutritional status, in these patients. Corticoids also appear to increase appetite, but their effects are short-lasting.

El síndrome caquéctico en el paciente oncológico: fisiopatología, manifestaciones clínicas y tratamiento farmacológico / Wasting syndrome in cancer patients: pathophysiology, clinical manifestations and drug therapy

El síndrome caquéctico está relacionado con un deterioro funcional del paciente que caracteriza a muchas patologías entre las que se incluyen el cáncer. El desarrollo de la caquexia engloba alteraciones metabólicas, hormonales y de otros mediadores celulares que desencadenan un síndrome de consunción que no puede resolverse mediante la ingesta forzada de nutrientes. El objetivo de este estudio es revisar los componentes fisiopatológicos de la caquexia, así como sus manifestaciones clínicas y las alternativas farmacológicas específicas en el tratamiento del cuadro caquéctico. Para ello se ha realizado una revisión de los artículos publicados en los últimos 4 años. El tratamiento farmacológico de la caquexia consiste en una serie de terapias combinadas que comprende el tratamiento de su enfermedad de base, la administración de soporte nutricional y tratamiento farmacológico específico para el cuadro caquéctico. Actualmente, la efectividad clínica de la ciproheptadina, hidrazina o pentoxifilina en el tratamiento de la anorexia es discutible. Únicamente los derivados de los progestágenos han sido capaces de incrementar el apetito y la ingesta en estos pacientes, así como mejorar su estado nutricional. Los corticoides también parecen incrementar el apetito, pero estos efectos son de corta duración (AU)

Ketotic hyperglycemia and epilepsia partialis continua.

Epilepsia partialis continua (EPC) may occur during nonketotic hyperglycemia but has not been described with diabetic ketoacidosis. The authors report a patient with EPC associated with ketotic hyperglycemia. Brain MRI showed two areas of abnormal signal intensity in the left precentral gyrus and in the right cerebellar hemisphere. Hyperglycemia may reduce seizure threshold because of the increase in gamma-aminobutyric acid metabolism and may trigger epileptic discharges.

Diffusion and perfusion MR imaging in cases of Alzheimer's disease: correlations with cortical atrophy and lesion load.

BACKGROUND AND PURPOSE: Perfusion and diffusion-weighted MR imaging are powerful new imaging techniques for evaluating tissue pathophysiology in association with many neurologic disorders, such as neurodegenerative diseases. The purpose of our study was to evaluate the sensitivity and specificity of dynamic susceptibility contrast-enhanced MR imaging and diffusion-weighted MR imaging in cases of Alzheimer's disease and to assess the role of atrophy in the quantification of cortical perfusion. METHODS: Thirty-nine participants were studied: 18 patients with moderate cognitive impairment with probable Alzheimer's disease, 16 patients with mild impairment with possible or probable Alzheimer's disease, and 15 group-matched elderly healthy comparison volunteers. Relative values of temporoparietal, sensorimotor, and hippocampal regional cerebral blood volume (rCBV) were measured as a percentage of cerebellar rCBV, and group classification was assessed with logistic regression. Brain atrophy was used as a covariate to assess its role in rCBV quantification. Regions of interest placed on orientation-independent apparent diffusion coefficient maps allowed the calculation of apparent diffusion coefficient values and relative anisotropic indices of the head of the caudate nuclei, thalamus, parietal, frontal, and hippocampal cortices bilaterally, genu and splenium of corpus callosum, and anterior and posterior white matter in patients with Alzheimer's disease and in control volunteers. RESULTS: Temporoparietal rCBV ratios were reduced bilaterally in the patients with Alzheimer's disease. Sensitivity was 91% in moderately affected patients with Alzheimer's disease and 90% in patients with mild cases. Specificity was 87% in healthy comparison volunteers. Lower values of sensitivity and specificity were obtained for sensorimotor (73%, 50%, and 67%, respectively) and hippocampal cortices (80%, 80%, and 65%, respectively). Using brain atrophy as a covariate, patients with Alzheimer's disease still showed a statistically significant reduction of rCBV compared with control volunteers. Diffusion-weighted MR imaging analysis only showed a trend, with no statistic significance, of reduction of anisotropy in posterior white matter. CONCLUSION: Dynamic susceptibility contrast-enhanced MR imaging of rCBV may be an alternative to nuclear medicine imaging for the evaluation of patients with Alzheimer's disease. When brain atrophy is used as a covariate, differences in rCBV still persist between patients with Alzheimer's disease and control volunteers, suggesting that perfusion impairment is unrelated to atrophy. No significant results for either white or gray matter were obtained using diffusion-weighted MR imaging.

Eficacia y tolerancia del oxaliplatino en el cáncer colorrectal avanzado / Efficacy and tolerability of oxaliplatin in advanced colorectal cancer

El oxaliplatino (OHP) es un análogo del cisplatino que ha demostrado actividad en líneas celulares resistentes al cisplatino. Su perfil de seguridad es diferente al del cisplatino y carboplatino. El efecto limitante de la dosis es la neurotoxicidad periférica, dependiente de la dosis acumulada y casi siempre reversible. No es nefrotóxico y es poco ototóxico y mielotóxico. Su toxicidad gastrointestinal suele controlarse bien con antieméticos. Para evaluar la eficacia en cáncer colorrectal avanzado, se ha realizado una búsqueda desde enero 1993 hasta enero 2000 en la base de datos Medline, seleccionando los ensayos clínicos publicados con oxaliplatino. También se han localizado otros ensayos clínicos mediante revisión de las citas bibliográficas, fundamentalmente aquellos presentados a congresos y no publicados aún. En los ensayos clínicos en cáncer colorrectal avanzado el OHP ha demostrado su eficacia tanto en monoterapia como, fundamentalmente, en combinación con 5-fluorouracilo, con el cual presenta actividad sinérgica. En los estudios comparativos aleatorizados fase III la asociación del oxaliplatino con 5-fluorouracilo y ácido folínico (5FU/AF) ha demostrado un aumento estadísticamente significativo de la tasa de respuestas frente al 5FU/AF sólo. También se ha demostrado una mejora significativa de la supervivencia libre (AU)

[The clinical efficacy of magnetic resonance with diffusion-weighted sequences in the assessment of acute cerebral ischemia]. / Efficacia clinica della Risonanza Magnetica con sequenze pesate in diffusione nella valutazione dell'ischemia cerebrale acuta.

PURPOSE: To evaluate the efficacy of diffusion weighted Magnetic Resonance Imaging in the diagnosis of acute ischemic infarction and correlate the signal changes observed in the acute phase with final brain damage. MATERIAL AND METHODS: Fifteen patients (six women and nine men: mean age 68 years) with acute ischemic stroke (within 12 hours) underwent diffusion MRI. All the patients were selected on the basis of sudden focal neurologic symptoms and CT findings excluding other conditions than ischemia. MRI was performed with a 1.5 T magnet with echo-planar gradients. All the patients underwent follow-up CT and/or MRI. RESULTS: Diffusion MRI, performed in the acute phase, showed signal changes in all the patients whose infarction was later confirmed by CT or MRI. In 10 of 12 patients with positive diffusion imaging, CT was normal. FLAIR sequences showed the lesions in 4 of 12 cases. In the 2 patients with transient ischemic attack diffusion MRI was normal as well as follow-up examinations. Apparent Diffusion Coefficients values in the infarcted area were almost half those of the contralateral normal brain. Final damage (as assessed by CT or MRI) was larger than observed in acute diffusion images in all cases but one. CONCLUSION: Because of its high sensitivity and specificity, diffusion MRI is going to play a more important role in the management of acute ischemic stroke patients.

[An evaluation of the carotid bifurcation and of the intracranial circle by angio-spiral computed tomography]. / Valutazione della biforcazione carotidea e del circolo intracranico mediante angio-Tomografia Computerizzata spirale.

INTRODUCTION: Some clinical trials (NASCET, ECTS) have assessed that carotid endarterectomy is protective against stroke in patients with asymptomatic severe carotid stenosis. In order to decrease costs and risks, new diagnostic tools have been developed, such as Magnetic Resonance Angiography (MRA), duplex Ultrasound (US) and more recently Spiral Computed Tomography Angiography (CTA). CTA provides excellent 3D angiography images of the extracranial vessels using a volume rendering technique. This study was aimed at prospectively evaluating the accuracy of CTA in the diagnosis of carotid bifurcation. The circle of Willis was also studied during the same bolus injection. DSA was used as the gold standard technique. Surgery was also used for comparison. MATERIAL AND METHODS: Spiral CTA and DSA were performed in 106 carotid bifurcations. DSA was performed in all patients within 48-72 hours of CTA. The degree of internal carotid stenosis was evaluated according to NASCET criteria. Degree of stenosis, presence of calcifications, ulcerations and tandem lesions were reviewed by two different neuroradiologists blinded to each other and to the results of the other technique. In 19 cases the size of residual lumen of the ICA was surgically evaluated and correlated with CTA. RESULTS: There was an overall correlation between CTA and DSA in 94% of cases. Our data are in agreement with the results of the current literature. CT angiograms overrated by one category 6 cases (25%) of mild and one of moderate stenosis (7.14%). Calcifications were seen on spiral CT angiography in 69 (65.09%) carotid bifurcations while DSA detected the presence in 31 (29.24%). Ulcerations were missed by CTA in 3 cases. Five (4.71%) tandem lesions were visualized by DSA distal to bifurcation: 2 (1.88%) were also diagnosed by CTA. The patency of the circle of Willis was assessed in all cases. In 19 cases, the size of ICA stenosis evaluated at surgery was comparable with CTA findings. CONCLUSIONS: In conclusion CTA offers an outstanding alternative to catheter angiography in the evaluation of stenosis-occlusion of the carotid bifurcation. The intracranial circulation can be easily assessed by CTA as well, which allows the study of tandem lesions and of the circle of Willis.

[Acute renal failure of obstructive etiology caused by uterine prolapse]. / Fracaso renal agudo de etiología obstructiva originado por prolapso uterino.

We describe a 76-year-old woman with severe uterine prolapse with secondary bilateral ureterohydronefrosis and acute renal failure, which improved after the reposition of the uterus. Physiopathological mechanisms and treatment of obstructive uropathy related with uterine prolapse are discussed.

[Hip prosthesis: idea, indications, development]. / Le artroprotesi dell'anca. L'idea, le indicazioni, l'evoluzione.

The authors describe the evolution and the successive stages that were necessary until the present total substitution of the hip joint could be worked out. The earliest attempts were made in 1923, but only in 1953, professor Marino Zuco, of Rome University Orthopedic Department started to carry out operations of arthroplasty, after 3 years of experimental research. In 1960, Charnley introduced the use of cement (methyl methacrylate), thus initiating the practice of total hip substitution. This surgery is indicated in a variety of joint pathologies of which osteoarthritis is the most frequent one. The implant of a cemented or non cemented prosthesis is conditioned both by the patient's age and by bone structure. Differences between the two types of prostheses are illustrated as well as the causes of failure or subsequent pathology and their diagnosis.

[Surgical treatment of gonarthrosis]. / Trattamento chirurgico della gonartrosi.

Gonarthosis, a frequent complaint in women over 50, brings about changes in the knee which alter its macro and micro structure and are responsible for alteration of the anatomical axis of the lower limb. The most frequent consequence is knock-knee leading to overloading of the medial compartment and reduction of the internal interosseous space. Whereas in the initial forms symptomatic therapy is the treatment of choice, in severe and advanced cases with complete articular blockage arthroprosthesis is the alternative and in cases with minor limitations of joint movement the best results are obtained by osteotomy intended to restore the correct axis. In order to evaluate which of the surgical techniques available is the most appropriate, the authors analyzed 40 cases of tibial osteotomy performed between 1974 and 1984. On the basis of the results obtained, cupuliform osteotomy above the tuberosity appears to lead to the highest success rate.