A high-score Mediterranean dietary pattern is associated with a reduced risk of peripheral arterial disease in Italian patients with Type 2 diabetes.

BACKGROUND: The 'Mediterranean diet' is considered to exert protective effects on cardiovascular disease, although a wide range of dietary patterns exists among subjects living even in the same Mediterranean country. OBJECTIVE: To investigate the association between specific dietary patterns and peripheral arterial disease (PAD) in Italian Type 2 diabetes patients. DESIGN: From a cohort of 944 patients with Type 2 diabetes, 144 patients with PAD were selected, and matched for age and sex with 288 Type 2 diabetic control patients without macrovascular complications. A dietary score was elaborated from a semiquantitative food frequency questionnaire. The higher the final score, the healthier the eating habit. RESULTS: In multivariate analysis, a higher score was independently associated with a significant reduction in PAD risk [odds ratio (OR) = 0.44; 95% confidence interval (CI) 0.24, 0.83]. Diabetes duration (OR > 15 years = 2.49; 95% CI 1.45, 4.25), hypertension (OR = 2.12; 95% CI 1.31, 3.45) and butter consumption (OR = 2.6; 95% CI 1.15, 3.68) were also significantly associated with PAD. The dietary score significantly improved the predictive value of models based on duration of diabetes and hypertension. (LSR = 2.19, DF = 7, P < 0.001). The effect of a high dietary score on the risk of PAD was independent of diabetes duration and hypertension. CONCLUSION: In Italian Type 2 diabetics, a higher dietary score has a protective role against PAD. The use of butter increases the risk of PAD even in patients regularly consuming olive oil. Dietary advice may be helpful for the prevention of PAD in diabetics even in populations traditionally accustomed to a Mediterranean dietary habit.

[Total parenteral nutrition. Analysis of the results of 144 treated cases]. / Nutrizione parenterale totale. Analisi dei risultati su 144 casi trattati.

Of 144 patients treated with T.P.N. in the period 1-5-1987/30-9-1988, 128 have been to have an operation. Their survival at the time of the removal, the post-operating mortality, the average stay in hospital, have been compared with those of other 128 patients non-treated with T.P.N., suffering from similar pathologies and who had operation of the same kind. The obtained results have stressed in the patients treated with T.P.N. as in those who had not, a survival at the time of the removal of 75% contrary to 62.5%, a post-operating mortality of 25% contrary to 37.5%, an average post-operative stay in hospital of 13 days contrary to 15 days. The statistical elaboration executed with chi 2's test with Yates' correction, provided 0.25 less than P greater than 0.50, so data non particularly meaningful. In our casuistry the percentage of surviving in the patients treated with T.P.N. as to those not treated, is nevertheless, very encouraging; furthermore, we most think that only by taking advantage of T.P.N. has been possible to extend the operability to patients that in the past because of well on years, or because of dangerous surgical illnesses joined to dismetabolic and cardiovascular diseases, were judged not operable.

Carcinoma of the pancreatic head area. Diagnostic imaging. Direct cholangiography: PTC.

The use of Chiba needle and a carefully performed procedure make percutaneous transhepatic cholangiography (PTC) highly diagnostic, with a low incidence of complications. However, because of their anatomy, visualization of pancreatic ducts, mandatory for an accurate diagnostic approach to the carcinomas of the pancreatic head area is impossible and thus this limits the diagnostic indications for PTC. At present it is performed in case of failure of endoscopic retrograde cholangiography (ERCP) or in view of interventional maneuvers. In carcinomas of the pancreatic head area PTC pattern is characterized by a more or less tight stenosis of the distal common bile duct with upward dilatation of biliary tree. The morphological features, the site and extent of stenosis usually permit a differential diagnosis between malignancies and benign forms (pancreatitis) while for definitive differentiation of cholangiocarcinoma from carcinoma of the pancreatic head infiltrating the common bile duct or from ampullary carcinoma, PTC should be combined with other imaging procedures.

Diagnostic imaging in deep vein thrombosis of the limbs.

The clinically suspected deep vein thrombosis (DVT) should always be confirmed by instrumental procedures. In fact, about 70% of patients with clinically suspected DVT are shown to be negative on instrumental investigations. Phlebography is still the gold standard in the diagnosis of peripheral DVT. Main phlebographic findings are: persistent filling defect; abrupt interruption of contrast in a vein; lack of opacification in all or some deep veins; flow diversion with opacification of collateral branches. At present, peripheral phlebography is performed when the other noninvasive exams (Color Doppler US and Duplex Doppler) are doubtful, technically limited or when thrombosis of innominate veins or superior vena cava, is suspected. Real-time US enables direct visualization of the limb proximal veins. The venous wall, the venous valves, the thrombus and its development, the anatomic variants, the perivenous structures which may impact on the normal physiology of venous return, are depicted. However, the distal veins of the leg and arm and deep veins (the iliac veins, the superficial femoral vein in the adductor canal) are not accurately visualized. The US findings in DVT include: the presence of echoes within the vascular lumen; the veins in axial scans are not compressible. Pulsed Doppler and duplex Doppler combine the morphologic and functional study. Injury caused by DVT at the valvular level (postphlebitic syndrome) is visualized. Primary deep vein thrombosis caused by valvular disorders (valvular aplasia) is identified. Inadequate superficial and perforating veins to be treated with surgery are mapped. Color Doppler US depicts directly superficial and deep limb veins combining the morphologic with the functional assessment represented by the visualization of the map of flow velocity and direction. Recently, a new diagnostic procedure, the color Doppler Energy (CDE) or Power Doppler has been introduced. Together with mean flow velocity and spectral variance, the signal energy or power is also analyzed. The CDE is independent of the US incidence angle, it does not shows the flow direction, detects particularly slow flows, early canalization of thrombi and non occlusive thrombosis. Color Doppler diagnosis of thrombosis is prompt because an area with absence of color is visualized. Collateral vessels and flow direction within them, is well depicted. Beside the site and extension of thrombosis, color Doppler US is able to directly visualize the distal end of the thrombus, which when floating is at high risk for embolism. CT allows an adequate study of the iliocaval axis and is useful if phlebography or color Doppler US are not diagnostic. Iliocaval thrombosis represents a not infrequent finding during abdominal CT. The thrombus appears as a hypodense mass encircled by the hyperdense rim of contrast medium.

Total body MR angiography and atherosclerosis.

The early detection of atherosclerotic vascular lesions is very important for diagnostic and interventional purposes. Traditionally, Digital Subtraction Angiography (DSA) is considered the reference diagnostic technique, but recently several new non-invasive procedures have been developed, like Doppler US, CT-angiography and MR-Angiography (MRA). MRA has progressively gained acceptance as a valid alternative. At present, the use of fast sequence and contrast injection allows to acquire segmental volumes within a few seconds (10-20s), with high diagnostic quality and accuracy. The systemic distribution of atherosclerosis requires the use of techniques which can assess the arterial system as exhaustively as possible. A MRA scanning protocol including all arteries from the epiaortic branches to the calf has recently been proposed with encouraging preliminary results. In this article, the relevant technical concepts in MRA and the present most important clinical findings are reported and discussed, including the proposed technique for a whole-body MR angiographic assessment of the atherosclerotic patient.

[The role of Doppler US in the study of carotid system]. / Il ruolo dell'eco-color-Doppler nello studio del distretto carotideo.

Color Doppler US is at present the most reliable noninvasive procedure in the diagnosis of carotid disease and plays a major diagnostic role in the patient at risk for stroke. The anatomofunctional relationships of carotid and vertebrobasilar system suggest a diagnostic combination between Doppler US and transcranial Doppler for complete hemodynamic evaluation of normal and pathologic cerebral vessels. The most relevant disease, as the cause of stroke, is represented by internal carotid atherosclerosis. Mechanisms by which the atheromatous plaque represents a cause of ischemia involve two factors: the embolic factor and the hemodynamic factor. The embolic factor is consequent on unstable plaques and US plays a major role in plaque characterization. Stenotic plaques are the major cause of the hemodynamic factor. Color Doppler US inables quantification of stenosis and selects surgical patients with greater than 70% stenosis. In internal carotid dissection as the acute cause of cerebrovascular insufficiency color Doppler US findings are significant for early diagnosis and follow-up.

Stent-graft and multilayer stent for treatment of type II thoracoabdominal aortic aneurysm in a high-risk patient.

The aim of the present article was to present an alternative endovascular treatment for type II thoracoabdominal aortic aneurysm that would have the advantage of limiting the duration of the procedure and the use of contrast. A high-risk patient was admitted to our Vascular Unit for type II thoracoabdominal aneurysm according to Crawford's classification. Two thoracic stent-grafts (Valiant Captivia, Medtronic, Pewaukee, WI, USA), a bifurcated stent-graft (Endurant Medtronic) and two multilayer stents (Cardiatis SA, Isnes, Belgium) were deployed. No postoperative major complications were observed. Operative time and use of contrast material were 45 min and 80 mL, respectively. Computed angiography tomography at 1 and 6 months showed patency of visceral and renal arteries and progressive thrombosis of the aneurysmal sac. This stent-graft treatment in combination with multilayer stent could be an alternative treatment for thoracoabdominal aneurysm in high-risk patients.

Purpura fulminans during meningococcal sepsis treated with Drotrecogin alpha. A clinical case.

A male patient, 29 years old, was admitted to our unit with purpura fulminans, coagulation deficiency, renal failure and subsequent septic shock accompanied by respiratory insufficiency in the absence of meningeal signs. The serum levels of endogenous protein C, ATIII and calcium were well below the norm. The bacteriological examination revealed the presence of gram-negative diplococci. The onset of adult respiratory distress syndrome (ARDS) revealed aa early complication of the meningococcal sepsis. Forty-eight hours after being admitted, the recombinant protein C infusion was started at a dose of 24 microg/kg/h for the duration of 96 h. The skin lesions regressed, starting from the ecchymosis and the edema of the face, trunk and auricular pavilions. A week after the onset of the symptomatology the chest X-ray appeared clear, the renal function had normalised, and the signs of shock had disappeared.

[Computer-assisted report generation and image transmission in bedside chest x-rays in intensive therapy units]. / Refertazione assistita e trasmissione delle immagini mediante computer nei toraci a letto dei reparti di terapia intensiva.

Since a few years ago, in our department the bedside chest X-rays of intensive care patients have been reported by means of a computer program which has also storing function. This computer program is a guideline for the radiologist and is organized in pages having a logical sequence. The program has proved very useful in learning the correct reporting of bedside chest X-rays. The nosographic data of the patients, the ventilatory and the technical data are stored for a better clinico-radiological correlation. The last four reports are displayed on the monitor to better understand the patient's history. The other reports become part of a "historical" archive. Most important is the cooperation with the referring physician: to make the most of it, a system has been implemented which sends the images from the Radiology Department to Intensive Care. The images are filmed with a camera and then digitalized on 1024 x 768 matrix with 16 million colors and 256 gray levels. Each workstation is composed of: AT286 computer with 60-MB hard disk, hardware or the digitalization and compression of images, a high-resolution monitor, an intercommunication system, and a modem. It is possible to zoom on the images, but a close-up on the image with the camera is better for improved spatial resolution. The images are stored on the hard disk: each image requires 3M bytes, but it can be compressed down to 25:1 with no detail loss. The images are transmitted via modem in at least 20 seconds/image. More images can be sent out-line. During transmission, it is possible to talk by the intercommunication system, pointing out structures on the monitor or drawing objects on both sides of the system. In our experience, image quality is good. We are therefore considering extending the network to other Departments and making the transmission of images of pathologic specimens possible. The natural evolution of this system is the teleconsult.

[Magnetic resonance angiography of the peripheral vessels with automatic moving bed infusion tracking]. / Angiografia con Risonanza Magnetica del circolo periferico con spostamento automatico del tavolo portapaziente.

PURPOSE: To investigate the actual diagnostic reliability of the Mobitrack technique with a slow intravenous infusion of paramagnetic contrast agent (CA) in MR Angiography of the peripheral arterial district. MATERIAL AND METHODS: Twelve healthy volunteers (mean age: 34) with no personal or family history of peripheral arterial pathologic conditions, underwent MR Angiography of the peripheral vascular district. A 1.5 T superconductive magnet equipped with automatic table feed was used. In the preliminary phase, the circulation time at the abdominal aorta was optimized and customized for each patient. This was done by performing a pre-targeting Fast Field Echo 2D (FFE 2D) sequence with intravenous administration of 1-2 mL CA by an injector, to evaluate the delay time. A 2D Time of Flight (2D TOF) sequence was then performed for topographic purposes. The partially overlapping volumes were acquired using Fast T1-weighted sequences, intravenous CA administration and an automatic table feed of 10 mm/s. A Fast Field Echo 3D (FFE 3D) T1-weighted sequence with TR/TE/FA: of 6.3/1.6/40 degrees and a slice thickness of 1.5 mm were also performed. Thirty to forty mL CA were slowly administered intravenously at a rate of 0.3-0.6 mL/s. Two blinded readers independently evaluated the images giving one of three diagnostic judgements: 1) arteries were well visualized, 2) heterogeneous arteries with(out) the presence of veins, and 3) arteries seen poorly or not at all. The first two judgements were considered diagnostic. The readers considered 19 different anatomical districts for each patient, giving a total of 190 evaluations. RESULTS: A blinded evaluation of the readers judgements did not indicate a statistically significant difference (agreement: 100%). Overall, 82% of the images were rated as 1, 8.5% as 2 and 8.4% as 3. DISCUSSION: In 174/190 judgements the vessels were rated as 1 or 2, that is of diagnostic value. Judgement 3 was always due to the inability to visualize the medial and/or distal third of the arterial circulation of the leg. CONCLUSIONS: The results of this technique optimization study confirm the overall validity of the Mobitrack technique. However they also indicate that further technical advances are required to ensure maximum diagnostic accuracy in this vascular district.

[Pulmonary thromboembolism and diagnostic imaging: integration of techniques and methods]. / Tromboembolia polmonare e diagnostica per immagini: integrazione di tecniche e metodiche.

Thromboembolism is presently the third most frequent cardiovascular disease, with an incidence of deep venous thrombosis of 800,000 cases a year in the USA. The clinical diagnosis of the condition is difficult and noninvasive procedures are poorly reliable, which makes the diagnosis and treatment of deep venous thrombosis appropriate in the patient with clinically suspected pulmonary embolism. Color-Doppler US is now replacing phlebography in the diagnosis of deep venous thrombosis. Proximal deep venous thrombosis is always at high risk for embolism (50%). Isolated calf thrombi may spread into proximal veins and thus cause severe embolism. Therefore, the early detection of thrombus site and extent and a timely treatment before embolism are of the utmost importance. Color-Doppler US is a noninvasive technique which can show deep venous thrombosis with 95% sensitivity in the proximal and 55% sensitivity in the distal districts in asymptomatic patients. This examination must be used not only to confirm a diagnostic suspicion of deep venous thrombosis, but also to screen high-risk patient and to monitor distal thrombosis. In the secondary prophylaxis of pulmonary embolism, the radiologist must perform a mechanical interruption of inferior vena cava by positioning a caval filter. Caval filters can be temporary or definitive; standard indications for caval filter positioning are a contraindication to anticoagulant therapy and the onset of pulmonary embolism in spite of anticoagulant drugs. A further indication is the presence of floating thrombi in the femoroiliac-caval trunk. Multidisciplinary groups including the hematologist, the radiologist and the clinician should plan the diagnostic and therapeutic approach and participate in the decision-making process. In our department, from January, 1992, to June, 1995, sixty-five caval filters were positioned in 62 patients selected out of 260 candidates. Three complications only were observed; one patient had recurrent pulmonary embolism and three patient had caval thrombosis spreading beyond the filter. In 198 patients in whom no caval filter was implanted, pulmonary embolism did not recur. At present, the role of the radiologist is markedly changing, especially in the management of this condition. On the one hand, radiologists must diagnose thromboembolism as a whole and not only its pulmonary evidence; on the other hand, they play a major operational and interventional role in the treatment of thromboembolism patients.

[Ovarian varicocele: percutaneous treatment. A preliminary note]. / Varicocele ovarico: trattamento percutaneo. Nota preliminare.

Incontinence of ovarian veins and development of adnexal varicosities (pelvic varicocele) seems to cause pelvic pain syndrome in about 50% of the cases. Whereas the diagnosis of male varicocele is usually clinical, the same diagnosis in a woman needs instrumental methods; therefore the number of diagnosed cases is lower than the real incidence of the disease. In the last 18 months 2 patients with ovarian varicocele and chronic pelvic pain have been successfully treated by percutaneous sclerotization of the gonadal veins with resolution of the pelvic pain syndrome. We preferred this interventional procedure to the surgical one, as is usually the case with male varicocele, where percutaneous therapy is considered the treatment of choice on the basis of long-term results, since its first attempt in 1977. Considering the effectiveness of this simple and non-surgical therapy for chronic pelvic pain, we stress the importance of correct and early diagnosis of pelvic varicocele.

Color Doppler ultrasonography in the differential diagnosis of focal hepatic lesions. The SH U 508 A (Levovist) experience.

The differential diagnosis of focal hepatic lesions is a current problem even though many study methods are available. Color Doppler US has been recently suggested as a diagnostic technique capable of depicting lesion vascularization patterns to better understand lesion nature. However, this examination is often difficult and long. In this study, we investigated the role of a US contrast agent SH U 508 A (Levovist) enhancing the color Doppler signals for easier and better depiction of lesion vascularization. Seventy-four patients with one or more focal hepatic lesions (mean diameter: 5.6 cm) were examined. The lesions were 38 HCCs, 4 cholangiocarcinomas, 1 intrahepatic biliary duct carcinoma, 1 case of multiple adenomas, 2 regenerations nodules in cirrhosis, 2 cases of FNH, 18 metastases and 8 hemangiomas. In 54 cases the US contrast agent allowed the visualization of some vessels inside the lesions which had been missed at baseline examinations. Moreover, the vessels which had been depicted on baseline images were better demonstrated. In all but one patient with severe hepatic steatosis, normal parenchymal vessels were markedly enhanced. Our results in the different kinds of tumors are here reported.