Concomitant Renal Artery and Aortic Aneurysm: Is Endovascular Surgery the Correct Approach?

Our case illustrates the concomitant presence of a giant aneurysm of the left renal artery at the ostium and an abdominal aortic aneurysm, in presence of a complex aortic anatomy. Type of approach and timing of the treatment is still not well established for the rare coexistence of these 2 pathologies. In case of surgical high-risk patients, endovascular therapy is considered now the best choice to exclude arterial and aortic aneurysms although there are chances to do further interventions in the follow-up. For this reason, we simultaneously treated both the aneurysms through an embolization with plugs and coils of renal aneurysm and endovascular exclusion of aortic aneurysm; in the follow-up, renal function of the patient worsened until hemodialysis and we saw the reperfusion of renal aneurysm and the onset of endoleak I type A from above the aortic and renal aneurysm and B from iliac legs of the previous endograft. We performed a parallel graft technique on visceral vessels to exclude the refilling of both aneurysms and preserve visceral vascularization. Follow-up at 12 months showed the complete exclusion of the aneurysms and the patency of stents in celiac trunk and superior mesenteric artery

A new approach for proximal anastomosis in type "A" acute aortic dissection: prosthesis eversion

One of the crucial aspects of surgical repair of type A aortic dissection is to achieve hemostasis of the anastomosis. Furthermore, the possibility of improving the suture with additional stitches is often technically demanding. We, therefore, describe a new surgical technique for the proximal anastomosis, positioning the prosthesis within the left ventricle. We present our series of 6 patients treated with this new technique. The immediate results confirmed the efficacy, speed, and simplicity of the technique. During long-term follow-up no patient showed significant residual aortic valve incompetence

"Delirium Day": A nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool

Background: To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy. Methods: This is a point prevalence study (called "Delirium Day") including 1867 older patients (aged 65 years or more) across 108 acute and 12 rehabilitation wards in Italian hospitals. Delirium was assessed on the same day in all patients using the 4AT, a validated and briefly administered tool which does not require training. We also collected data regarding motoric subtypes of delirium, functional and nutritional status, dementia, comorbidity, medications, feeding tubes, peripheral venous and urinary catheters, and physical restraints. Results: The mean sample age was 82.0 \ub1 7.5 years (58 % female). Overall, 429 patients (22.9 %) had delirium. Hypoactive was the commonest subtype (132/344 patients, 38.5 %), followed by mixed, hyperactive, and nonmotoric delirium. The prevalence was highest in Neurology (28.5 %) and Geriatrics (24.7 %), lowest in Rehabilitation (14.0 %), and intermediate in Orthopedic (20.6 %) and Internal Medicine wards (21.4 %). In a multivariable logistic regression, age (odds ratio [OR] 1.03, 95 % confidence interval [CI] 1.01-1.05), Activities of Daily Living dependence (OR 1.19, 95 % CI 1.12-1.27), dementia (OR 3.25, 95 % CI 2.41-4.38), malnutrition (OR 2.01, 95 % CI 1.29-3.14), and use of antipsychotics (OR 2.03, 95 % CI 1.45-2.82), feeding tubes (OR 2.51, 95 % CI 1.11-5.66), peripheral venous catheters (OR 1.41, 95 % CI 1.06-1.87), urinary catheters (OR 1.73, 95 % CI 1.30-2.29), and physical restraints (OR 1.84, 95 % CI 1.40-2.40) were associated with delirium. Admission to Neurology wards was also associated with delirium (OR 2.00, 95 % CI 1.29-3.14), while admission to other settings was not. Conclusions: Delirium occurred in more than one out of five patients in acute and rehabilitation hospital wards. Prevalence was highest in Neurology and lowest in Rehabilitation divisions. The "Delirium Day" project might become a useful method to assess delirium across hospital settings and a benchmarking platform for future surveys

Acute occlusion of the abdominal aorta

The Authors report on two cases of acute aortic occlusion, related to cardiac embolism and thrombosis of aortic aneurysm. The singularity of the etiology adds interest to a pathology which is already, in itself, serious and complex and which requires the intervention of the surgeon, anesthesiologist-reanimator, cardiologist, and nephrologist. The diagnosis is mainly clinical. The use of Doppler and CT scan provide to achieve the diagnosis. Surgical treatment included transfemoral embolectomy, with a Fogarty catheter, in the patient with acute aortic occlusion related to cardiac embolism, and aortobifemoral bypass, in the other patient, affected by thrombosis of aortic aneurysm

L'ecocolordoppler nello studio della pseudo occlusione della carotide interna

The differentiation of pseudo-occlusion from complete internal carotid artery occlusion may have important clinical consequences for patients with the former tend not to benefit from reconstructive surgery. The Authors report a case in which color-Doppler duplex-scanner revealed a persisting string-like lumen that was not demonstrated by angiography. The Authors believe that ultrasonography may in future permit the reliable differentiation of pseudo-from complete carotid occlusion, thereby reducing the need for angiography

Combined administration of growth hormone-releasing hormone and clonidine restores defective growth hormone secretion in old dogs

We have studied in old dogs the effects of short-term administration of growth hormone (GH)-releasing hormone (GHRH) alone or co-administered with clonidine (CLO), an alpha2-adrenergic agonist, on the GH secretory pattern (cluster analysis), and GH responsiveness to an acute GHRH or GHRH + CLO challenge and plasma somatomedin C (SMC) levels. Dogs were given either GHRH alone twice daily for 10 days (treatment 1) or combined GHRH + CLO both given twice daily (treatment 2) or GHRH + CLO given once daily (treatment 3). Animals were sampled from 09.00 to 15.00 h, at 10-min intervals, both before and 14 h after treatments. At the end of the 6-hour sampling period, dogs were challenged with simultaneous administration of GHRH and CLO, while they were tested with GHRH alone on the morning of the following day. In dogs undergoing treatment 1, acute administration of GHRH or GHRH + CLO elicited mean GH peak responses higher than before treatment, but none of the GH secretory indices were modified during the 6-hour sampling period, except for the increase in mean GH peak amplitude. In dogs undergoing treatment 2, acute administration of GHRH elicited a mean GH peak response higher than that before treatment, whereas administration of GHRH + CLO induced a mean GH peak response not different from that elicited by GHRH + CLO before treatment or by GHRH alone after treatment. However, this treatment significantly augmented the frequency of spontaneous bursts of GH secretion, the mean GH peak amplitude and the total peak area. In dogs undergoing treatment 3, acute administration of GHRH alone or GHRH + CLO elicited a mean GH peak response higher than that elicited by the same drugs before treatment. Moreover, there was an increase of GH peak frequency, mean GH peak amplitude and total peak area, even higher than after treatment 2. Plasma SMC levels rose significantly after all treatments, treatment 3 being the most effective in this instance. These data demonstrate that: (1) both a hypothalamic and a pituitary component play a role in the defective GH secretion in old dogs; (2) GH hypofunction is not an irreversible event, since GH secretion may be restored by pharmacological means acting at both the pituitary and the hypothalamic level, and (3) CLO given only once daily was more effective than CLO given twice daily, perhaps due to the property of this drug to down-regulate at high doses hypothalamic alpha2-adrenoceptors

Central mechanisms subserving the impaired growth hormone secretion induced by persistent blockade of NMDA receptors in immature male rats.

Recently, we have reported in immature female rats that short-term blockade of glutamate receptors of the N-methyl-D-aspartic acid (NMDA) subtype by the noncompetitive antagonist MK-801 induced a reduction of growth rate, basal and stimulated growth hormone (GH) release and plasma somatomedin C levels. In the present study, we investigated in immature male rats the mechanism(s) through which agonists and antagonists of glutamate receptors affect GH secretion. In 21-day-old male rats, administration of MK-801 (0.2 mg/kg i.p. b.i.d.) for 10 days induced a significant impairment of growth rate, which was unrelated to a significant reduction of food intake. GH secretion from anterior pituitary fragments of MK-801-treated rats was not significantly reduced under basal conditions but was significantly less under stimulation by 40 mM K+. Incubation of dispersed pituitary cells of 31-day-old rats with N-methyl-aspartic acid (1 and 100-mu-M), alone or associated with MK-801 (1-mu-M) did not change GH secretion. Semi quantitative densitometric analysis of hypothalami of MK-801-treated rats evidenced a clearcut decrease in the intensity of GHRH-like immuno-reactivity (LI) staining in the median eminence (ME), whereas no differnece was observed in the ME-somatostatin (SS)-LI. Finally, GHRH mRNA but not SS-mRNA, evaluated by slot-blot hybridization, was reduced in the hypothalamus of MK-801-treated rats. These and our previous data would demonstrate that NMDA glutamate receptors play an important role in the neuroendocrine control of GH secretion in the rat, and suggest an action mediated by GHRH-secreting neurons