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Background: Atherosclerosis is a systemic process, involving multiple arterial districts at the same time. Carotid doppler ultrasound is an easy and non-invasive test, able to evaluate the layers of the neck arteries and the involvement of this district in the atherosclerotic process. Carotid intima-media-thickness (IMT) is known to be a marker of the systemic atherosclerotic process. Dopper ultrasound could become useful, allowing a correct risk stratification in the systemic involvement by the atherosclerotic process. Moreover, it could be functional, in association with the other already-validated rulers, in targeting the best therapeutic choice for acute coronary heart disease [6]. An increase of IMT or the presence of atherosclerotic plaque in asymptomatic patients have been associated to an increased risk for coronary heart disease (CHD) in large, perspective studies [1–4]. On the other hand, a recent meta-analysis [5] showed that neither the presence of an increased IMT neither the presence of a plaque were discriminatory enough to be considered a reliable screening test among patients with symptomatic CHD. Aims of the study: To evaluate a correlation between carotid arteries ultrasonographic pattern and coronaric pathology extension among symptomatic CHD patients living in our region. Materials and methods: In the period 01/2007–01/2008, we enrolled 100 consecutive patients admitted to our Internal Medicine Department for acute coronary syndrome (ACS). For each patient, we evaluated the classical risk factors (familiarity, known CHD, diabetes mellitus, dyslipidemia, hypertension, smoke and obesity), the extent of the atherosclerotic pathology (cerebrovascular events, peripheral arteries pathology and CHD) and the therapy at the moment of the admission. Every subject underwent to doppler ultrasound: IMT, presence of carotid plaque and degree of stenosis were evaluated. Coronarographic assessment evaluated the number of arteries with significant obstruction, the total coronary score (TCS), the site and the degree of stenosis. We performed the statistical analysis with SPSS 13.0 package for Windows systems. Results: The absence of a previous history of CHD and a negative carotid ultrasound (normal IMT, no evidence of any plaque) were the strongest protective factors for multiple-vessel coronary disease (CHD: OR = 0.132; 95% CI 0.027–0.628, p\0.05; Negative US: OR = 0.223; 95% CI: 0.067–0.742, p\0.05). Lower percentages of stenosis were associated to lower TCS as detected at coronarography (0–30% stenosis at US: OR = 6.76 [95% CI: 19.25–2.37, p\0.05] of obtaining a low TCS) with a decrease of the risk of low TCS with proportional to the increase of carotid stenosis. Discussion: In this small, retrospective analysis we correlate a normal carotid ultrasonographic pattern with a low risk of multiple-vessel involvment at coronarography. Moreover, in this population of symptomatic patients, we correlate the percentage of carotid stenosis with a proportional increase of the risk of an higher TCS at coronarography. These data suggest that among high-risk, symptomatic patients, carotid ultrasound and doppler evaluation can be a reliable indicator of the extent of coronary pathology. References 1. Simon A, Chironi G, Levenson J (2007) Comparative performance of subclinical atherosclerosis tests in predicting coronary heart disease in asymptomatic individuals. Eur Heart J 28(24):2967–2971 (review) 2. Chambless LE, Heiss G, Folsom AR, Rosamond W, Szklo M, Sharrett AR, Clegg LX (1997) Association of coronary heart disease incidence with carotid arterial wall thickness and major risk factors: the Atherosclerosis Risk in Communities (ARIC) Study, 1987–1993. Am J Epidemiol 146:483–494 3. O’Leary DH, Polak JF, Kronmal RA, Manolio TA, Burke GL, Wolfson SK Jr (1999) Carotid-artery intima and media thickness as a risk factor for myocardial infarction and stroke in older adults. Cardiovascular Health Study Collaborative Research Group. N Engl J Med 340:14–22 4. Salonen T, Salonen R (1991) Ultrasonographically assessed carotid morphology and the risk of coronary heart disease. Arterioscler Thromb 11:1245–1249 5. Wald DS, Bestwick JP (2009) Carotid ultrasound screening for coronary heart disease: results based on a meta-analysis of 18 studies and 44,861 subjects. J Med Screen 16(3):147–154 6. Flu WJ, van Kuijk JP, Hoeks SE, Kuiper R, Schouten O, Goei D, Winkel T, van Gestel YRBM, Verhagen HJM, Bax JJ, Poldermans D, Rotterdam, and Leiden, The Netherlands, Coronary Artery Disease Intima media thickness of the common carotid artery in vascular surgery patients: a predictor of postoperative cardiovascular events

Case report: We report a case of two successful pregnancies in a patient with a prior diagnosis of essential thrombocytemia with secondary portal vein thrombosis and portal hypertension. A 19-year-old woman affected by undefined thrombocytosis (platelets count 650,000 mmc-1) since 1990 was admitted to our department in May 1995 for severe abdominal pain and hepatosplenomegaly. History was negative for smoking or autoimmune disorders and laboratoristic exams showed a slight increase of leukocytes, erythrocytes, hemoglobin, transaminases, bilirubin, and decreased PT. Portal hypertension secondary to inferior vena cava thrombosis was confirmed by Doppler evaluation that revealed the presence of a complete splenoportal occlusion. Ultrasonographic assessment showed also severe hepatosplenomegaly and presence of ascites. Thrombolytic therapy with urokinase was started within 3 h from the admission. She underwent to diuretic and beta-blocking ther- apy, with gradual remission of the presenting clinical features and progressive reperfusion of the vessel. Recanalization of the portal axis was documented by ultrasound and subsequent MRI with contrast medium. Bone marrow aspiration and biopsy resulted highly suggestive for essential thrombocytemia (ET), and the cause of the clinical epiphenomena were referred to this chronic mye- loproliferative syndrome. A course of interferon-alpha, according to literature, was started and subsequent follow-ups showed a stability of clinical and laboratoristic data. Two years later, the patient was admitted again for the occurrence of ascites, subcutaneous venous collaterals and acute bleeding of oesophageal varices. She underwent to endoscopic band ligation in the emergency depart- ment. CT scan and subsequent MRI with arteriographic evaluation of splancnic arteries and veins were highly suggestive of Budd- Chiari syndrome with subsequent portal and splancnic hyperten- sion. Imaging suggested the presence of hypervascular nodules in the liver, narrowing of the vena cava and left hepatic vein occlusion. Liver biopsy showed areas of nodular hyperplasia. On- cocarbide was started, and patient was put in list for liver transplantation. Orthotopic liver transplantation was performed in November 1998, with a regular clinical course. Serial clinical and laboratoristic controls were in the normal range. In the following years patient continued her therapy with interferon-alpha. Despite her clinical history, she had two uncomplicated pregnancies after withdrawal of oncocarbide. Currently both the patient and her children are doing well. Discussion: Essential thrombocythemia (ET) is an acquired mye- loproliferative disorder with a prolonged clinical course and a near- normal life expectancy [1, 2]. It is characterized by a sustained elevation of platelet number with an increased risk for thrombosis and hemorrhage. Whereas most of the patients with ET are asymptomatic, some may experience vasomotor, thrombotic, or hemorrhagic disturbances. Arterial and venous thromboses, as well as platelet-mediated transient occlusions of the microcirculation and bleeding, represent the main risks for ET patients. This pathology has been described to complicate pregnancy with recurrent abortions, intrauterine death, and fetal growth retardation due to placental infarctions [3]. However, pregnants affected by ET have often a favourable outcome. An increased risk for thrombosis is always present among pregnants, and it can be increased in the ET subgroup. On the other hand, hemorrhagic risk is low, except in patients with acquired Von Willebrand’s disease [4]. Many pregnancies in ET have a successful outcome with minimal ther- apy. Cytoreductive treatment should preferably be avoided, especially during the first trimester [5]. Moreover, none of these has a product license for use in pregnancy. Interferon use has been associated with a higher live birth rate, whereas ASA treatment didn’t affect any major outcome [2]. IFN-a does not cross the placental barrier, and represents a potential therapeutic solution when platelet reduction is required for high risk patients. Reducing the platelet count using IFN-a might improve the chance of a successful outcome in subsequent pregnancies [5]. References 1. Birgega ̊rd G (2009) Long-term management of thrombocytosis in essential thrombocythaemia. Ann Hematol 88(1):1–10 2. Melillo L, Tieghi A, Candoni A et al (2009) Outcome of 122 pregnancies in essential thrombocythemia patients: A report from the Italian registry. Am J Hematol 84(10):636–640 3. Buyukbayrak EE, Ergen B, Karageyim Karsidag AY et al (2010) Successful pregnancy in a patient with portal hypertension secondary to portal vein thrombosis due to essential thrombocythaemia: a rare case. J Matern Fetal Neonatal Med 23(2):187–189 4. Griesshammer M, Heimpel H, Pearson T (1996) Essential thrombocythemia and pregnancy. Leuk Lymphoma 22(Suppl 1):57–63 5. Jean B Brie`re (2007) Essential thrombocythemia. Orphanet J Rare Dis 2:3. doi:10.1186/1750-1172-2-3

Barrett's esophagus (BE) is an acquired disorder due to chronic gastroesophageal reflux. Environmental factors seem to play an important role in the pathogenesis of BE, especially in Western society. A multicenter case-control study was carried out between February 1995 and April 1999 in 8 Italian Departments of Gastroenterology gathered in a study group (GOSPE), in order to analyze the influence of some individual characteristics and life-style habits on the occurrence of BE. Three groups of patients were studied: 149 patients with BE, 143 patients with esophagitis (E) and 308 hospital controls (C) with acute, non-neoplastic, non-gastroenterological conditions. The diagnosis of BE was based on endoscopy and histology. E was defined by the Savary classification (grade I–III). Data collection was performed by using a questionnaire that focused on smoking, coffee and alcohol consumption, medical history, drugs history, gastroesophageal reflux disease (GERD) symptoms (heartburn, regurgitation) and socio-economic status. Multivariate analysis showed that the frequency of weekly GERD symptoms was significantly associated with both BE and E (p

Cystic duct cannulation during endoscopic retrograde cholangiography is now possible, due to advances in endoscopic equipment and methodology. The aim of this study was to assess the role of endoscopic transpapillary cholecystostomy in inoperable patients with acute cholecystitis.Between October 1993 and February 1996, cystic duct cannulation was performed in 15 patients with acute cholecystitis (9 men and 6 women; mean age 74.8 years. Acute calculous cholecystitis was associated with cholangitis in 4 cases, with pancreatitis in 2 cases, and with perforation of the gallbladder in 1 case.Cystic duct cannulation was successful in 13 patients (86.6%), and resulted in remission of cholecystitis by nasovesicular drainage associated with antibiotherapy in all cases. No morbidity and mortality due to this method was observed at one month. No recurrence was observed after a mean follow-up of 8 months (range: 6 weeks-14 months).This study suggests that endoscopic nasovesicular drainage is a good alternative treatment to percutaneous cholecystostomy in inoperable patients.