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BACKGROUND AND PURPOSE: Inflammatory changes in the fat tissue surrounding the coronary arteries have been associated with coronary artery disease and high-risk vulnerable plaques. Our aim was to investigate possible correlations between the presence and degree of perivascular fat density and a marker of vulnerable carotid plaque, namely contrast plaque enhancement on CTA. MATERIALS AND METHODS: One-hundred patients (76 men, 24 women; mean age, 69 years) who underwent CT angiography for investigation of carotid artery stenosis were retrospectively analyzed. Contrast plaque enhancement and perivascular fat density were measured in 100 carotid arteries, and values were stratified according to symptomatic (ipsilateral-to-cerebrovascular symptoms)/asymptomatic status (carotid artery with the most severe degree of stenosis). Correlation coefficients (Pearson ρ product moment) were calculated between the contrast plaque enhancement and perivascular fat density. The differences among the correlation ρ values were calculated using the Fisher r-to-z transformation. Mann-Whitney analysis was also calculated to test differences between the groups. RESULTS: There was a statistically significant positive correlation between contrast plaque enhancement and perivascular fat density (ρ value = 0.6582, P value = .001). The correlation was stronger for symptomatic rather than asymptomatic patients (ρ value = 0.7052, P value = .001 versus ρ value = 0.4092, P value = .001). CONCLUSIONS: There was a positive association between perivascular fat density and contrast plaque enhancement on CTA. This correlation was stronger for symptomatic rather than asymptomatic patients. Our results suggest that perivascular fat density could be used as an indirect marker of plaque instability.

We investigated whether coronary flow reserve (CFR) can be modified by tadalafil, a long-acting phosphodiesterase 5 (PDE5) inhibitor, in patients with documented coronary artery disease (CAD). CFR was non-invasively evaluated in 12 men with a positive history for erectile dysfunction (ED) and angiographically documented CAD, in the distal portion of the left anterior descending coronary artery, free from critical stenosis, with contrast enhanced echocardiography at time zero (T0). Then, after 20 mg tadalafil was orally administered CFR measurement was repeated after 2 h (T1) and after 24 h (T2). Doppler curves suitable for the analysis were obtained in all patients (CFR feasibility: 100%). The peak diastolic velocity after adenosine infusion increased from 71.3+/-14.3 cm/s at T0 to 82.5+/-24.0 at T1 (P=NS) and to 89.5+/-21.1 at T2 (P=0.0010). CFR after tadalafil increased significantly from 2.6+/-0.3 at T0 to 3.1+/-0.7 at T1 (P=0.0078) and a further increment was found at T2 (3.5+/-0.9; P=0.0010 vs T0). Our study shows that oral administration of tadalafil exerts a long standing, potentially beneficial effect on coronary microvasculature in patients with ED.

Background Pulmonary arterial hypertension (PAH) is a life-threatening and debilitating complication of several connective tissue diseases. We aimed to evaluate the effects of long-term treatment with bosentan, an oral dual endothelin ET A /ET B receptor antagonist, in a cohort of patients with PAH related to connective tissue diseases. Material and methods In the present prospective, noncontrolled study, 13 patients (nine with systemic sclerosis, two with systemic lupus erythematosus, one with mixed connective tissue disease and one with overlap syndrome including scleroderma and myositis), mostly nonresponders to prostanoids therapy, were treated for 1 year with bosentan. Cardiac haemodynamics and the diagnosis of PAH were performed by Doppler ultrasound examination. Exercise capacity was assessed by 6-min walking test at baseline and at 3, 6 and 12 months of therapy. Results During bosentan treatment, progressive improvement of exercise capacity was observed.Walk distance increased in seven patients, remained unchanged in three and slightly decreased in three patients. A progressive significant decrease of right ventricular systolic pressure was also observed, whereas pulmonary artery mean pressure remained unchanged. Adverse effects related to bosentan (elevation of hepatic aminotransferases) were noted in two patients. Conclusion Long-term treatment with bosentan was effective in improving exercise capacity and pulmonary haemodynamics in patients with PAH related to connective tissue diseases.

Our purpose was to investigate the multi-detector-row CT angiography (MDCTA) application in endoleak detection.Fifty-nine patients that underwent endovascular aneurysm repair (EVAR) of an infrarenal abdominal aortic aneurysm with endoluminal stent graft were retrospectively studied. MDCTA scans were obtained after administration of 110-130 mL of contrast material using a 4-6 mL/sec flow rate. We made unenhanced, arterial (15-20 sec) and delayed (100 sec) acquisitions. For each patient four MDCTA datasets (pre-EVAR, 1, 6, and 12 months follow-up) were obtained. Each examination was studied by two observers. Kappa value was calculated in order to evaluate inter-observer agreement.Twenty-one endoleaks were detected in eighteen patients. Fifteen and eighteen endoleaks were detected by using biphasic arterial CT and biphasic delayed CT respectively (sensitivity of 71.4% and 85.7% respectively). We observed a positive correlation between the presence of endoleak and the increasement in aneurysm size. Interobserver agreement was 88.1% and kappa value was 0.685.Biphasic CT for endoleak detection is significantly superior to arterial and delayed phases respectively. We observed a good interobserver agreement.

Abdominal aortic aneurysms (AAA) are an important cause of death in elderly men. Most used treatment options are endovascular aneurysm repair (EVAR) and open surgical repair. After the endovascular stent graft placement, however, several complications may occur and an important complication of EVAR is endoleak formation which occurs in approximately one-fourth of patients. Endoleak represents a blood flow outside the stent graft lumen but within the aneurysm sac. For these reasons, unlike the minimal imaging follow-up that is typically performed after surgical repair, patients undergoing EVAR require a life-long postoperative surveillance imaging. In the last years, with the advent of multidetector-row CT (MDCT) scanners and the use of specific angiographic protocols (multidetector CT angiography, MDCTA), CT imaging became the most commonly used examination for endoleak detection. Moreover, the volume data obtained can be further rendered to generate high quality two-dimensional (2D) and three-dimensional (3D) images, that allow a better distinction between Endoleak type II, III and IV. Purpose of this study was to review and describe MDCTA potentialities in the detection of endoleak after EVAR procedures.

Background: Marfan's syndrome is an inherited disorder of connective tissue associated with characteristic abnormalities of the skeletal, ocular, and cardiovascular systems. Marked clinical variability and age dependency of all manifestations of Marfan's syndrome may render the unequivocal diagnosis difficult in mildly affected, young subjects. Hypothesis: The study and care of a 32-year-old woman with evidence of Manfan's syndrome, several cardiac abnormalities, and paranoid schizophrenia led to an investigation of her consenting relatives to verify the penetrance of Marfan's syndrome and the degree of comorbidity between the disease and psychiatric disorders. Methods: The patient and 12 subjects belonging to three generations of her family underwent cardiovascular, skeletal, ophthalmologic, and psychiatric examinations. Two-dimensional and Doppler echocardiography were performed. Results: One female index patient and six of her first-degree relatives were found to be affected by Marfan's syndrome. All seven patients were found to have mitral valve prolapse associated with other cardiac abnormalities. Four of these patients were affected by the following psychiatric disorders: generalized anxiety disorder, major depressive disorder, paranoid schizophrenia (two cases). Six more relatives without Marfan's syndrome showed mitral valve prolapse in association with other echocardiographic features. Two of these were found to be affected by a major depressive disorder. Conclusions: The present data support the hypothesis that a psychiatric condition, associated with a significantly high frequency of cardiac involvement, may be part of the phenotype of Marfan's syndrome.

BACKGROUND AND PURPOSE: Carotid plaque ulceration is an important risk factor for stroke, and its diagnosis may be very important to plan a correct therapeutic approach. We hypothesized that axial scans and various reconstruction methods could have different specificity and sensitivity in the study of plaque ulceration. The object of this study was to evaluate their role and diagnostic efficacy in patients with carotid plaque complicated by ulceration through the comparison with surgical results. Materials and METHODS: From January 2004 to November 2005, 109 patients who underwent a carotid endarterectomy were analyzed using CT angiography for a total of 218 carotid arteries. We assessed every carotid for the presence of ulcerations. For each patient axial image, maximum intensity projection (MIP), multiplanar reconstruction (MPR), shaded surface display (SSD), and volume rendering (VR) reconstructions were obtained. RESULTS: Multidetector row CT angiography (MDCT) found 32 ulcerations; surgical confirmation underlined an overall 93.9% sensitivity (95% confidence interval [CI] 0.858–1.021), and a 98.7% specificity (95% CI, 0.961–1.012). Axial scans and volume rendering images demonstrated the highest sensitivity (90.9% and 87.9%, respectively); SSD, on the contrary, showed the lowest sensitivity: 39.4% (95% CI sensitivity, 0.227–0.561). CONCLUSION: Axial scans plus VR reconstruction techniques offer superior depiction of carotid plaque ulceration compared with MIP, MPR, and SSD.

We tested the hypothesis that coronary flow reserve (CFR) in the left anterior descending coronary artery (LAD) as assessed by a new noninvasive method (contrast-enhanced transthoracic second harmonic echo Doppler) is in agreement with CFR measurements assessed by intracoronary Doppler flow wire.Contrast-enhanced transthoracic second harmonic echo Doppler is a novel noninvasive method to detect blood flow velocity and reserve in the LAD. However, it has not yet been validated versus a gold-standard method.Twenty-five patients undergoing CFR assessment in the LAD by Doppler flow wire were also evaluated by contrast-enhanced transthoracic Doppler to record blood flow in the distal LAD at rest and during hyperemia obtained by adenosine i.v. infusion. In five patients CFR was evaluated twice (before and after angioplasty).As a result of the combined use of i.v. contrast and second harmonic Doppler technology, feasibility in assessing coronary flow reserve equaled 100%. The agreement between the two methods was high. In fact, in all but five patients the maximum difference between the two CFR measurements was 0.38. Overall, the prediction (95%) interval of individual differences was -0.69 to +0.72. Reproducibility of CFR measurements was also high. The limits of the agreement (95%) between the two measurements were -0.32 to +0.32.Coronary flow reserve in the LAD as assessed by contrast-enhanced transthoracic echo Doppler along with harmonic mode concurs very closely with Doppler flow wire CFR measurements. This new noninvasive method allows feasible, reliable and reproducible assessment of CFR in the LAD.

The purpose of this study is to evaluate the feasibility in detecting blood flow in the left anterior descending coronary artery (LAD) using transthoracic color Doppler (CD) imaging (in both second harmonic and fundamental mode) along with contrast enhancement and to verify if this new noninvasive method along with adenosine is safe, rapid and effective in assessing coronary flow reserve (CFR).Feasibility of contrast-enhanced transthoracic Doppler recording (in both second harmonic and fundamental mode) of blood flow velocity in the LAD has not been assessed. Adenosine has a greater vasodilator potency and more favorable kinetics than dipyridamole and thus it can be more suitable for assessing CFR in conjunction with this method.Sixty-one patients with angiographically patent LAD underwent CD (both in fundamental and harmonic mode) as well as color-guided pulsed wave (PW) Doppler recording of blood flow velocity in the distal LAD before and after intravenous contrast injection. A second group of patients (n = 77), undergoing coronary angiography, was submitted to transthoracic contrast-enhanced PW Doppler recording of blood flow velocity in the LAD using harmonic CD as a guide, at rest and during adenosine-induced hyperemia.Harmonic CD along with echo contrast consistently improved blood flow detection in the LAD; the success rate in detecting flow of optimal quality was 88% with this approach, whereas it was 11% and 16% with CD in fundamental mode, respectively, before and after contrast. Pulsed wave Doppler results paralleled those of harmonic CD (p0.001 contrast harmonic vs. fundamental). In the second group of patients coronary angiography revealed 0% to40% stenosis in 24 patients (group I),or =40% toor =75% in 17 patients (group II) and75% stenosis in 34 patients (group III). There was a significant difference in CFR among the three groups of patients; CFR for peak diastolic velocity was (mean +/- SD): 2.88+/-0.7 (group I), 2.09+/-0.5 (group II) and 1.51+/-0.5 cm/s (group II) (p0.05 group I vs. both group II and group III; p0.05 group II vs. group III). The whole examination took less than 10 min.Contrast-enhanced second harmonic Doppler recording of blood velocity in the LAD is highly feasible and in combination with adenosine it is a rapid, safe and effective method for assessing CFR ratio.

Hydatidosis is particularly widespread in some geographic areas. Among these Sardinia presents one of the highest incidences. The authors examine the results obtained of 382 patients submitted to surgery between 1973 and 1989. The average age was 38.9 years. Liver involvement was observed in 215 cases, lung involvement in 167 cases, while localizations in other organs were rare. Forty liver cysts and 54 lung cysts were complicated preoperatively. The patients were submitted predominantly to total or subtotal cysto-pericystectomy (270 cases), parenchymal resection (75 cases), simple cystectomy (40 cases). Total postoperative mortality was 2.35%. Postoperative time was significantly shorter after cysto-pericystectomy and after parenchymal resection than after simple cystectomy. Patients suffering from multiple or complicated cysts were given supplementary chemotherapy.

A retrospective analysis is presented of 195 consecutive patients with chest trauma, hospitalized from 1976 to 1984 at the Institute of Pathology and Surgery of the University of Cagliari. The most frequent causes were traffic accidents. In 11 patients the trauma was penetrating while 184 presented with blunt trauma. Conservative treatment was performed in 106, pleural drainage or thoracentesis in 29, and surgery in 60. Early osteosynthesis was performed in the 22 patients with flail chest and in 15 with multiple depressed fractures. Total mortality was 4.1%, and 13.6% in patients with flail chest. All deaths were associated with significant extrathoracic injuries.

The localization of substance P is studied in the human prevertebral sympathetic ganglia and descending colon by the indirect immunofluorescence technique. Strongly immunoreactive axons reach the coeliac, superior mesenteric and inferior mesenteric ganglia. The sympathetic postganglionic neurones are surrounded by a meshwork of positive beaded fibers and terminals. Varicose nerve fibers are variously distributed in all nonepithelial layers of the colon. A close network of fibers and terminal surrounds the ganglionic cells in the mienteric and submucous plexuses. Substance P-like immunoreactive perikarya are present in these structures.

The Authors report the results of a study on 204 patients anesthetized with epidural administration of buprenorphine with bupivacaine. The data obtained were compared with a sample of 236 patients treated with local anesthetic alone. On the whole, the first group of patients presented better anesthesia, with a significantly longer anesthetic effect and more effective sedative and postoperative analgesic effects. Side effects observed were of acceptable entity and incidence.

The presence of substance P- and enkephalin-like immunoreactive nerve fibers and terminals is demonstrated in the human paravertebral sympathetic ganglia by an indirect immunofluorescence technique. Substance P-positive nerve structures appear in the form of fiber bundles, isolated varicose filaments and dot-like and basket-like nerve terminals around the neuronal cell bodies. Their density shows a remarkable individual variability. Enkephalin-positive nerve structures appear as isolated varicose filaments and dot-like nerve terminals, forming densely innervated patchy areas. No substance P- or enkephalin-containing cell bodies were detected. No overlapping seems to exist among the areas innervated by the two types of neuropeptides.