Lipoprotein(a) and homocysteine as genetic risk factors for vascular and neuropathic diabetic foot in type 2 diabetes mellitus

Neuropathy and peripheral artery disease represent the main pathophysiological conditions underlying diabetic foot. Several studies showed that Lipoprotein(a)-Lp(a)-and homocysteine (Hcy) can be associated with diabetic complications, but their relationship with diabetic foot is unclear. Aim of this study was to investigate whether Lp(a) and Hcy were associated with diabetic foot ulcerations, classified according to the presence of peripheral artery disease (PAD) or neuropathy. From among consecutive type 2 diabetic attending at the Diabetic Foot Clinic 27 subjects with vascular diabetic foot (VDF), 43 with neuropathic diabetic foot (NDF) and 52 controls without foot ulceration, neuropathy, and PAD were enrolled. Both Lp(a) (26.1 ± 22.7 vs. 14.9 ± 19.5 mg/dl; P = 0.003) and Hcy levels (15.4 ± 5.7 vs. 12.2 ± 5.1 μmol/l; P = 0.022) were significantly greater in the VDF group than in controls. Lp(a) levels were significantly lower in the NDF group than in controls (6.9 ± 8.1 versus 14.9 ± 19.5 mg/dl; P = 0.009), while no difference in Hcy levels was found. Multiple logistic regression analysis showed that Hcy was associated with VDF (OR: 1.11; 95% CI: 1.07-14.1; P = 0.048). Lp(a) did not enter the model, but its P-value was very near to the significant level (OR: 1.09; 95% CI: 0.99-12.05; P = 0.059). Moreover, low Lp(a) levels were associated with NDF (OR: 0.84; 95% CI: 0.21-0.96; P = 0.039). Our study has shown for the first time that high Lp(a) and Hcy levels are associated with the development of VDF, while low Lp(a) levels appear to be associated with delayed wound healing in patients with neuropathic foot ulcerations.     

Impact of anti-rheumatic drugs and steroids on clinical course and prognosis of COVID-19

Clinical Rheumatology -     

Pancreatic multicenter ultrasound study (PAMUS)

Aim

To describe the typical CEUS pattern of pancreatic lesions and to evaluate the diagnostic accuracy of Contrast-enhanced ultrasound (CEUS) in their characterization.

Materials and methods

All US and CEUS examinations of focal pancreatic masses performed in six centers during a period of five years were reviewed. Inclusion criteria were: focal pancreatic mass pathologically proved, visible at ultrasound (US) and studied with CEUS. All lesions were then evaluated for size, aspect and enhancement pattern. Sensitivity, specificity, positive and negative predictive values with 95% CIs were calculated to define diagnostic accuracy of CEUS in respect to pathology. Diagnostic confidence of US and CEUS, discerning between benign and malignant lesions, were represented by using ROC (receiver operating characteristics) curves. Agreement was evaluated by means of k statistics.

Results

1439 pancreatic lesions were included. At CEUS the lesions were divided into solid (89%) and cystic (12%) masses and classified into six and eight categories, respectively. Among the solid lesions, adenocarcinomas were characterized with an accuracy of 87.8%. Among the cystic lesions, cystic tumors were diagnosed with an accuracy of 97.1%. ROC curve area increased from 0.637 for US to 0.877 for CEUS (p < 0.0001). Inter-observer agreement was slightly higher for solid (k = 0.78) than cystic (k = 0.62) lesions. In none of the centers side effects were reported.

Conclusion

CEUS is accurate in the characterization of pancreatic lesions. CEUS should be considered as a complementary imaging method for pancreatic lesions characterization.     

Chemotherapy with or without estrogenic recruitment in metastatic breast cancer. A randomized trial of the Gruppo Oncologico Nord Ovest (GONO)

BACKGROUND:: This phase III study was carried out to verify whether a kineticrecruitment induced with low doses of diethylstilbestrol (DES)could increase the antitumor activity of chemotherapy in patientswith advanced breast cancer. PATIENTS AND METHODS:: Two hundred fifty-eight women with metastatic breast cancerwere randomized to receive chemotherapy consisting of cyclophosphamide600 mg/sqm i.v., epidoxorubicin 60 mg/sqm i.v. and fluorouracil600 mg/sqm i.v. (CEF) on day 1 or DES-CEF (diethylstilbestrol1 mg orally days 1–3 CEF on day 4) every 21 days. Patientswere treated until progression or, if responsive, for a maximumof 10 courses. RESULTS:: There were no significant differences between the two treatmentarms in response rates (51.3% to CEF and 49.6% for DES-CEF);median progression-free survival (9.4 months for CEF and 11months for DES-CEF group) or median overall survival (17.3 and20 months for CEF and DES-CEF arms, respectively). Non-hematologicaltoxicities were superimposable in the two arm, while DES-chemo-therapywas more myelotoxic. CONCLUSIONS:: This trial confirms that chemotherapy preceded by estrogenicrecruitment is still in an experimental phase and that, at present,it has no role in clinical practice. Further research is neededto test the possibility of combining different mitogens in thelight of new information about breast cancer cell growth. estrogenic recruitment, metastatic breast cancer     

Reoperation for aortic false aneurysms: our experience and strategy for safe resternotomy

BACKGROUND AND AIM OF THE STUDY: To review our experience with reoperation for aortic false aneurysms (FA) and to present an analysis of the relevant surgical approaches and risks. METHODS: From May 1999 to June 2006, 11 patients underwent a total of 13 reoperations due to aortic false aneurysms, with an incidence of 3% of all thoracic aortic cases. Cardiopulmonary bypass (CPB) and cooling were started before sternotomy in all cases. Three different strategies were adopted for patients depending on the position of the FA in the mediastinum as indicated by a preoperative CT scan. These included: deep hypothermic circulatory arrest (18 degrees C), moderate hypothermia (28 degrees C), and mild hypothermia (32 degrees C). In two patients, the sternotomy ruptured the FA causing profuse hemorrhaging. In all the other cases sternotomy was performed without complication. The repair consisted in simple repair by direct suture (10 cases) or extensive repair by refashioning the anastomosis (three cases). RESULTS: Two hospital deaths occurred with a hospital mortality rate of 16.7%. Permanent neurological deficit developed in one patient. Transient neurological deficit in the form of left lower limb weakness was observed in one patient. False aneurysm recurrence developed in two cases. Among patients present at follow-up (nine survivors), four are in NYHA class I and five in class II. CONCLUSIONS: Aortic false aneurysms carry a high mortality and morbidity rate. Nevertheless, we believe that selecting the right strategy according to the position of the FA in the chest can reduce surgical risk, thus permitting relatively safe resternotomy.     

Acoustic Radiation Force Impulse (ARFI) ultrasound imaging of solid focal liver lesions

Objective

The aim of this paper was to evaluate the application of ARFI ultrasound imaging and its potential value for characterizing focal solid liver lesions.

Materials and methods

In this multicentric prospective study, over a total non-consecutive period of four months, all patients underwent ARFI US examination. Two independent operators performed 5 measurements per each lesion and 2 measurements in the surrounding liver. According to the definitive diagnosis, a mean velocity value and standard deviations were obtained in each type of focal solid lesion, compared by using t-test, and the inter-operator evaluation was performed by using the Student's t-test. A comparison between the total mean values of each type of lesion and the mean value of the parenchyma was performed.

Results

40 lesions were evaluated and a total of 400 measurements were obtained. The lesions were: 6/40(15%) hepatocellular carcinomas, 7/40(17.5%) hemangiomas, 5/40(12.5%) adenomas, 9/40(22.5%) metastases and 13/40(32.5%) focal nodular hyperplasias. The total mean values obtained were: 2.17 m/s in HCCs, 2.30 m/s in hemangiomas, 1.25 m/s in adenomas, 2.87 m/s in metastases and 2.75 m/s in FNHs. The inter-operator evaluation resulted non-statistically different (p > 0.05). A significant difference (p < 0.05) was always found by comparing adenomas to the other lesions. 160 measurements were obtained in the surrounding parenchyma, with a no significant difference between values measured in adenomas and in the surrounding liver.

Conclusions

ARFI technology with Virtual Touch tissue quantification could non-invasively provide significant complementary information regarding the tissue stiffness, useful for the differential diagnosis of focal solid liver lesions.     

Aspergillus flavus-infection of a pacemaker wire: continuing evidence for active management of infected pacemakers

A rare case of fungal endocarditis (Aspergillus flavus) on a permanent pacemaker is described. Owing to negative blood culture and non-specific echocardiographic findings, a complete diagnosis was made only on histologic examination of the surgically removed material. In our opinion this case supports an active management of infected pacemakers.     

Executive Functioning in Older Adult Outpatients With Type 2 Diabetes Mellitus: A Preliminary Study

Given the multi-componential nature of executive functions, we compared 48 outpatients affected by Type 2 diabetes and 49 control subjects on the executive domains of inhibition, updating, shifting, and word fluency. Variables commonly associated with diabetes were considered in explaining the relationship between diabetes and executive functioning. Each participant underwent a clinical and cognitive (addressing the four executive domains) evaluation. Raw test scores were standardized per domain and compared between groups. Possible risk factors related to diabetes were examined. The diabetes group scored lower than the control subjects only in the inhibition measure, whereas no differences resulted in the other executive domains.