Infrapopliteal revascularization in diabetic foot ischemia: correlation between morphologic and clinical results

ABSTRACT Purpose: To retrospectively evaluate angiographic and clinical outcomes of percutaneous revascularization in diabetic patients with Fontaine stage IV critical limb ischemia (CLI). Materials and Methods: Clinical and procedural data were retrospectively collected of consecutive diabetic patients with Fontaine stage IV CLI who underwent percutaneous limb revascularization from January 2009 to June 2011. Pre- and post-procedural angiographic images were retrospectively reviewed to classify lower limb arterial involvement according to 3 systems: 1) TASC II; 2) Graziani’s morphological classification; 3) Joint Vascular Society Council calf and foot scores. Foot lesions were graded according to the Texas University (TU) classification. Clinical results (healing, stability or major amputation) were compared to baseline clinical data and angiographic results. Results: In the study period, 202 percutaneous procedures were performed, with an immediate technical success rate of 93.6%. The majority of ulcers (75.7%) were deep (TU grades 2 and 3). Mean preprocedural calf and foot scores were 7.81.6 and 7.32.3, respectively; 132 patients (65.3%) were in Graziani’s morphological classes from 4 to 7 (at least two arteries occluded); in 112 (55.4%) cases TASC II was inapplicable (only infrapopliteal involvement). After the procedure, mean calf and foot scores were 4.82.3 and 5.92.6, respectively, and 86.6% of cases were into the Graziani’s classes 1 and 2, whereas TASC II was inapplicable in all cases. Healing rate was 66.8% and major amputation rate was 3.9%. Among all the clinical and angiographic variables included in the analysis, only pre- and post-procedural foot scores were significantly associated to the clinical outcome (p=0.04). Conclusion: TASC II is inadequate to describe vascular involvement in the vast majority of diabetic patients with CLI. In this population, percutaneous revascularization should represent the first-line treatment option, leading to high healing and limb salvage rates. Pre- and post-procedural foot scores significantly affect chances of healing, thus aggressive treatment of foot arteries should be attempted whenever possible

The Effect of Human Milk on Modulating the Quality of Growth in Preterm Infants

Introduction: Human milk is the optimal nutrition for preterm infants. When the mother's own milk is unavailable, donor human milk is recommended as an alternative for preterm infants. The association among early nutrition, body composition and the future risk of disease has recently attracted much interest. The aim of this study was to investigate the effect of human milk on the body composition of preterm infants.Materials and Methods: Very low birth weight infants (VLBW: birth weight <1,500 g) with a gestational age (GA) between 26 and 34 weeks were included. Clinical data, anthropometric measurements and nutritional intake in terms of the volume of human milk were extracted from computerized medical charts. The human milk intake was expressed as a percentage of target fortified donor human milk and/or target fortified fresh mother's milk, compared with the total volume of milk intake during the hospital stay. All included infants underwent anthropometric measurements and body composition analysis (expressed as fat-free mass percentage) at term corrected age (CA) by air-displacement plethysmography. A comparison between infants fed human milk at <50% (group 1) and infants fed human milk at ≥50% of the total volume of milk intake (group 2) was conducted. Multiple linear regression analyses were conducted to explore the modulating effect of fortified human milk on fat-free mass at term CA.Results: Seventy-three VLBW infants were included in the study. The mean weight and GA at birth were 1,248 ± 198 g and 30.2 ± 2.0 weeks, respectively. No differences were found regarding anthropometric measurements at birth, at discharge and at term CA between the two groups. The mean fortified human milk intake was 34.9 ± 12.5 and 80.9 ± 15.5% in groups 1 and 2, respectively (p < 0.001).A multiple regression analysis corrected for sex and birth weight demonstrated that intake of ≥50% fortified human milk was associated with a higher fat-free mass percentage at term CA than intake of <50% fortified human milk.Conclusion: The use of target fortified human milk modulated growth and improved growth quality in vulnerable preterm infants. Thus, the use of donor human milk should be encouraged when fresh mother's milk is insufficient or not available

Guidelines on the diagnosis, treatment and management of visceral and renal arteries aneurysms: a joint assessment by the Italian Societies of Vascular and Endovascular Surgery (SICVE) and Medical and Interventional Radiology (SIRM)

: The objective of these Guidelines is to provide recommendations for the classification, indication, treatment and management of patients suffering from aneurysmal pathology of the visceral and renal arteries. The methodology applied was the GRADE-SIGN version, and followed the instructions of the AGREE quality of reporting checklist. Clinical questions, structured according to the PICO (Population, Intervention, Comparator, Outcome) model, were formulated, and systematic literature reviews were carried out according to them. Selected articles were evaluated through specific methodological checklists. Considered Judgments were compiled for each clinical question in which the characteristics of the body of available evidence were evaluated in order to establish recommendations. Overall, 79 clinical practice recommendations were proposed. Indications for treatment and therapeutic options were discussed for each arterial district, as well as follow-up and medical management, in both candidate patients for conservative therapy and patients who underwent treatment. The recommendations provided by these guidelines simplify and improve decision-making processes and diagnostic-therapeutic pathways of patients with visceral and renal arteries aneurysms. Their widespread use is recommended

Energy Expenditure, Protein Oxidation and Body Composition in a Cohort of Very Low Birth Weight Infants

The nutritional management of preterm infants is a critical point of care, especially because of the increased risk of developing extrauterine growth restriction (EUGR), which is associated with worsened health outcomes. Energy requirements in preterm infants are simply estimated, so the measurement of resting energy expenditure (REE) should be a key point in the nutritional evaluation of preterm infants. Although predictive formulae are available, it is well known that they are imprecise. The aim of our study was the evaluation of REE and protein oxidation (Ox) in very low birth weight infants (VLBWI) and the association with the mode of feeding and with body composition at term corrected age. Methods: Indirect calorimetry and body composition were performed at term corrected age in stable very low birth weight infants. Urinary nitrogen was measured in spot urine samples to calculate Ox. Infants were categorized as prevalent human milk (HMF) or prevalent formula diet (PFF). Results: Fifty VLBWI (HMF: 23, PFF: 27) were evaluated at 36.48 ± 0.85 post-conceptional weeks. No significant differences were found in basic characteristics or nutritional intake in the groups at birth and at the assessment. No differences were found in the REE of HMF vs. PFF (59.69 ± 9.8 kcal/kg/day vs. 59.27 ± 13.15 kcal/kg/day, respectively). We found statistical differences in the protein-Ox of HMF vs. PFF (1.7 ± 0.92 g/kg/day vs. 2.8 ± 1.65 g/kg/day, respectively, p < 0.01), and HMF infants had a higher fat-free mass (kg) than PFF infants (2.05 ± 0.26 kg vs. 1.82 ± 0.35 kg, respectively, p < 0.01), measured with air displacement plethysmography. Conclusion: REE is similar in infants with a prevalent human milk diet and in infants fed with formula. The HMF infants showed a lower oxidation rate of proteins for energy purposes and a better quality of growth. A greater amount of protein in HMF is probably used for anabolism and fat-free mass deposition. Further studies are needed to confirm our hypothesis

Efficacy and Safety of a Novel Vascular Closure Device (Glubran 2 Seal) After Diagnostic and Interventional Angiography in Patients with Peripheral Arterial Occlusive Disease

To prospectively evaluate safety and efficacy of a novel vascular closure device (Glubran 2 Seal) after peripheral angiography in patients with peripheral arterial occlusive disease (PAOD). From December 2010 to June 2011, all consecutive patients with PAOD undergoing peripheral angiography were prospectively enrolled onto the study after percutaneous antegrade or retrograde puncture of the common femoral artery. After angiography, the Glubran 2 Seal device was used to achieve hemostasis. The following data were registered: technical success and manual compression duration, patients' discomfort (scale 0-5), operators' technical difficulty (scale 0-5), and vascular complications. The site of hemostasis was evaluated by clinical inspection and color-coded Duplex ultrasound performed 1 day and 1 month after the procedure. One hundred seventy-eight patients were enrolled (112 male, mean age 70.8 years) with a total of 206 puncture sites, including 104 (50.5 %) antegrade accesses. The device was successful in 198(96.1 %) of 206 procedures, with 8 cases of manual compression lasting longer than 5 min (maximum 20 min). No major vascular complications were observed, resulting in 100 % procedural success. Minor complications occurred in seven procedures (3.4 %), including two cases of pseudoaneurysms, successfully treated by ultrasound-guided glue injection. The mean +/- A standard deviation score for patients' discomfort was 0.9 +/- A 0.7, whereas the mean score for operators' difficulty was 1.2 +/- A 0.9. In patients with PAOD, the Glubran 2 Seal represents a simple, painless, and efficient vascular closure device, able to achieve hemostasis both in antegrade and retrograde accesses

Commentario breve alla riforma "Jobs Act"

Il volume tende all’esame approfondito del complessivo disegno regolatore oggi universalmente conosciuto come Jobs Act : di conseguenza, ripercorrere, come si cercherà di fare nelle pagine che seguono, la trama dell’opera e gli istituti introdotti o modfiicati dal legislatore significa riavvolgere l’ordito della riforma attorno ad un unico, forse immaginario, file rouge

Commentario breve alla riforma "Jobs Act"

Il volume tende all’esame approfondito del complessivo disegno regolatore oggi universalmente conosciuto come Jobs Act : di conseguenza, ripercorrere, come si cercherà di fare nelle pagine che seguono, la trama dell’opera e gli istituti introdotti o modfiicati dal legislatore significa riavvolgere l’ordito della riforma attorno ad un unico, forse immaginario, file rouge