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Purpose: To evaluate if jugular vein flow restoration in various venographic defects indicative of chronic cerebrospinal venous insufficiency (CCSVI) in multiple sclerosis (MS) patients can have positive effects on cerebral lesions identified using magnetic resonance imaging (MRI). Materials and Methods: The Brave Dreams trial ( ClinicalTrials.gov identifier NCT01371760) was a multicenter, randomized, parallel group, double-blind, sham-controlled trial to assess the efficacy of jugular venoplasty in MS patients with CCSVI. Between August 2012 and March 2016, 130 patients (mean age 39.9±10.6 years; 81 women) with relapsing/remitting (n=115) or secondary/progressive (n=15) MS were randomized 2:1 to venography plus angioplasty (n=86) or venography (sham; n=44). Patients and study personnel (except the interventionist) were masked to treatment assignment. MRI data acquired at 6 and 12 months after randomization were compared to the preoperative scan for new and/or >30% enlargement of T2 lesions plus new gadolinium enhancement of pre-existing lesions. The relative risks (RR) with 95% confidence interval (CI) were estimated and compared. In a post hoc assessment, venograms of patients who underwent venous angioplasty were graded as “favorable” (n=38) or “unfavorable” (n=30) for dilation according to the Giaquinta grading system by 4 investigators blinded to outcomes. These subgroups were also compared. Results: Of the 130 patients enrolled, 125 (96%) completed the 12-month MRI follow-up. Analysis showed that the likelihood of being free of new cerebral lesions at 1 year was significantly higher after venoplasty compared to the sham group (RR 1.42, 95% CI 1.00 to 2.01, p=0.032). Patients with favorable venograms had a significantly higher probability of being free of new cerebral lesions than patients with unfavorable venograms (RR 1.82, 95% CI 1.17 to 2.83, p=0.005) or patients in the sham arm (RR 1.66, 95% CI 1.16 to 2.37, p=0.005). Conclusion: Expanded analysis of the Brave Dreams data that included secondary/progressive MS patients in addition to the relapsing/remitting patients analyzed previously showed that venoplasty decreases new cerebral lesions at 1 year. Post hoc analysis confirmed the efficacy of the Giaquinta grading system in selecting patients appropriate for venoplasty who were more likely to be free from accumulation of new cerebral lesions at MRI.

Ischemic colitis is the most common form of intestinal ischemia. Diagnosis is made at clinical examination and endoscopy and completed by vascular imaging, but color Doppler US may become a first-line imaging technique for the evaluation of the mesenteric circulation.We present the case of an 80-year-old woman hospitalized for recurrent ischemic colitis of the sigmoid. At a previous hospitalization, color Doppler US examination showed medium to severe stenosis at the origin of the inferior mesenteric artery. However, CT angiography was negative and the condition was therefore misdiagnosed. Eight months later the patient was admitted again with abdominal pain and rectal hemorrhage. Rectosigmoidoscopy documented the presence of ischemia of the sigmoid mucosa. Angiography showed the presence of severe stenosis at the origin of the inferior mesenteric artery so revascularization was carried out by percutaneous transluminal angioplasty (PTA) during the same session. Follow-up showed normal patency of the inferior mesenteric artery after revascularization, and subsequent endoscopic evaluation documented gradual colonic mucosal ischemia resolution. Blood flow at the level of the inferior mesenteric artery was assessed using color Doppler US. The presented case confirms that color Doppler US is a valid first-line imaging technique in the assessment of ischemic intestinal lesions. It is reliable in the evaluation of the mesenteric arterial circulation, and it also allows assessment of blood flow alterations caused by stenosis and identification of localized hemodynamic stenosis which may be missed at CT-angiography or MR-angiography. Arteriography remains the examination of choice in case of discrepancy between first-and second-line imaging techniques and in all cases which offer the possibility of endovascular revascularization.SommarioLa colite ischemica è la forma più frequente di ischemia intestinale. La diagnosi è clinica ed endoscopica ed è completata dall’imaging vascolare. Lo studio Eco-Color Doppler può rappresentare la metodica d’imaging di primo livello nella valutazione del circolo mesenterico.Presentiamo il caso di una donna di 80 anni ricoverata per recidiva di colite ischemica del sigma. Dopo un primo ricovero con Eco-Color Doppler che evidenziava stenosi medio-elevata all’origine della arteria mesenterica inferiore, ma Angio-TC negativa e diagnosi finale misconosciuta, la paziente presentava insorgenza di dolore addominale e rettoragia e veniva effettuato un nuovo ricovero ospedaliero. La rettosigmoidoscopia documentava la presenza di ischemia della mucosa del sigma. Veniva quindi effettuato uno studio angiografico che evidenziava la presenza di stenosi critica dell’arteria mesenterica inferiore all’origine e si procedeva nella stessa seduta a rivascolarizzazione mediante angioplastica percutanea transluminale.I successivi controlli evidenziavano normale pervietà dell’arteria mesenterica inferiore dopo rivascolarizzazione; la successiva valutazione endoscopica ha documentato la graduale risoluzione dell’ischemia della mucosa colica con restitutio ad integrum. Per valutare il flusso a livello dell’arteria mesenterica inferiore è stato effettuato follow-up mediante Eco-Color Doppler.Il caso in esame conferma che, nella patologia ischemica intestinale l’Eco-Color Doppler rappresenta una metodica di imaging di primo livello, affidabile, per la valutazione del circolo arterioso mesenterico; consente inoltre, valutando le alterazioni di flusso secondarie alla stenosi, di individuare stenosi emodinamiche localizzate che possono sfuggire alla valutazione mediante metodiche di secondo livello quali l’Angio-TC o l’Angio-RM. L’arteriografia rimane l’esame di scelta nel caso di discordanza tra metodiche di primo e secondo livello e in tutti i casi in cui si preveda la possibilità di una rivascolarizzazione endovascolare.

The enhancement of circulating endothelial progenitor cells (EPCs) obtained by exercise training can be beneficial to patients with cardiac disease. Changes in the levels and differentiation of CD34(pos)/KDR(pos) EPCs, as well as the plasma concentration of vascular endothelial growth factor (VEGF) and stromal cell-derived factor (SDF)-1 EPC-mobilizing cytokines, were evaluated in patients with chronic heart failure after 8 weeks of supervised aerobic training (SAT) and 8 weeks of subsequent discontinued SAT (DSAT).The levels of circulating EPC and EPC differentiation potential of 22 patients who underwent SAT were studied by fluorescence-activated cell sorter analysis and colony forming-unit assay, respectively. The plasma levels of VEGF and SDF-1 were measured by enzyme-linked immunosorbent assay. In response to SAT, the levels of both EPC and VEGF/SDF-1 markedly increased (P.001 vs baseline) but returned to the baseline levels after DSAT. A similar change was observed with the EPC clonogenic potential, but on DSAT the baseline level was incompletely attained.In response to SAT, patients with chronic heart failure show enhanced EPC levels and clonogenic potential that is mirrored by increased plasma VEGF and SDF-1 levels. DSAT can interfere with the maintenance of training-acquired VEGF/SDF-1-related EPC levels and clonogenic potential.

Opinion is divided regarding the influence of iodized oil on MRI signal intensity of hepatic tumours treated with transcatheter arterial chemoembolization (TACE), in which lipiodol deposits. The aim of our study was to ascertain whether or not lipiodol directly influences the MRI signal intensity of hepatocellular carcinoma (HCC) treated by TACE and that of the surrounding liver. Thirteen patients with HCC were studied retrospectively. CT and MRI scans were performed both before and 3 months after TACE. The CT scan was performed to check whether embolized nodules contained lipiodol and how lipiodol was distributed within them. In addition, eight patients were examined prospectively within 7 days after TACE. In these patients a CT scan was performed to see how lipiodol was distributed in the neoplastic nodules and in normal hepatic parenchyma. In the first group of patients the contrast-to-noise (C/N) ratio on T1-weighted (T1W) images and the T2 relaxation time on T2-weighted (T2W) images were calculated for both neoplasm and surrounding liver. In the second group of patients we also measured the signal intensity of non-neoplastic liver that was either permeated or not permeated by lipiodol. The data were analysed with Wilcoxon's test. On T1W images we observed that the retention of lipiodol increased the C/N ratio in all the tumours studied within 1 week after TACE. In the patients studied 3 months after TACE the C/N ratio was not significantly increased. On T2W images lipiodol retention did not change tumour signal intensity. The iodized oil did not change the signal intensity of the liver surrounding the tumour, in comparison with the liver not permeated by lipiodol, on either T1W or T2W images. The results indicate that lipiodol does not modify the signal intensity in non-neoplastic hepatic parenchyma in which it is deposited; after 3 months it does not significantly affect the signal of the tumours that accumulated it. Lipiodol produces a high signal on T1W images over the first few days following TACE in those tumours in which it is deposited.

Education and diagnostic tests capable of early detection represent our most effective means of preventing transmission of human immunodeficiency virus (HIV). The importance of early detection is underlined by studies demonstrating increased life expectancy following early initiation of antiviral treatment. The Elecsys(®) HIV combi PT assay is a fourth-generation antigen-antibody combination assay developed to allow earlier detection of seroconversion, and to have increased sensitivity and improved specificity. We aimed to determine how early the assay could detect infection compared with existing assays; whether all HIV variants could be detected; and the assay's specificity using samples from blood donors, routine specimens, and patients with potential cross-reacting factors. Samples were identified as positive by the Elecsys(®) assay 4.9 days after a positive polymerase chain reaction result (as determined by the panel supplier), which was earlier than the 5.3-7.1 days observed with comparators. The analytical sensitivity of the Elecsys(®) HIV combi PT assay for the HIV-1 p24 antigen was 1.05 IU/mL, which compares favorably with the comparator assays. In addition, the Elecsys(®) assay identified all screened HIV subtypes and displayed greater sensitivity to HIV-2 homologous antigen and antibodies to HIV-1 E and O and HIV-2 than the other assays. Overall, the specificity of the Elecsys(®) assay was 99.88 % using samples from blood donors and 99.81 % when analyzing unselected samples. Potential cross-reacting factors did not interfere with assay performance. The Elecsys(®) HIV combi PT assay is a sensitive and specific assay that has been granted the CE mark according to Directive 2009/886/EC.

Objectives To confirm whether sirolimus-eluting stents (SES) safely reduce the incidence of restenosis in patients with ST-segment elevation acute myocardial infarction compared with bare-metal stents (BMS). Background In the setting of primary angioplasty, stent restenosis occurs in up to 27% of patients. The introduction of drug-eluting stents has drastically reduced the incidence of restenosis in clinically stable patients. Methods We conducted a randomized trial of 320 patients with acute ST-segment elevation myocardial infarction assigned to receive SES or BMS. The primary end point was binary restenosis at 1-year angiographic follow-up. Results At 1 year, the incidence of binary restenosis was lower in the SES group than in the BMS group (9.3% vs. 21.3%, respectively; p = 0.032), as were the rates of target lesion revascularization (4.3% vs. 11.2%; p = 0.02), target vessel revascularization (5% vs. 13.1; p = 0.015), major adverse cardiac events (6.8% vs. 16.8%; p = 0.005), and target vessel failure (8.7% vs. 18.7%; p = 0.007). The incidence of angiographically documented stent thrombosis was 1.2% (n = 2) in the SES group and 0.6% (n = 1) in the BMS group. Conclusions In patients with acute myocardial infarction, SES are superior to BMS, reducing the incidence of binary restenosis by 56%, target lesion revascularization by 61%, target vessel revascularization by 62%, adverse cardiac events by 59%, and target vessel failure by 53% at 1 year. (Sirolimus Eluting Stenting in Acute Myocardial Infarction; http://www.clinicaltrials.gov/ct/show/NCT00288210; NCT00288210)

Background Multi-element interventions for first-episode psychosis (FEP) are promising, but have mostly been conducted in non-epidemiologically representative samples, thereby raising the risk of underestimating the complexities involved in treating FEP in ‘real-world’ services. Methods/Design The Psychosis early Intervention and Assessment of Needs and Outcome (PIANO) trial is part of a larger research program (Genetics, Endophenotypes and Treatment: Understanding early Psychosis - GET UP) which aims to compare, at 9 months, the effectiveness of a multi-component psychosocial intervention versus treatment as usual (TAU) in a large epidemiologically based cohort of patients with FEP and their family members recruited from all public community mental health centers (CMHCs) located in two entire regions of Italy (Veneto and Emilia Romagna), and in the cities of Florence, Milan and Bolzano. The GET UP PIANO trial has a pragmatic cluster randomized controlled design. The randomized units (clusters) are the CMHCs, and the units of observation are the centers’ patients and their family members. Patients in the experimental group will receive TAU plus: 1) cognitive behavioral therapy sessions, 2) psycho-educational sessions for family members, and 3) case management. Patient enrolment will take place over a 1-year period. Several psychopathological, psychological, functioning, and service use variables will be assessed at baseline and follow-up. The primary outcomes are: 1) change from baseline to follow-up in positive and negative symptoms’ severity and subjective appraisal; 2) relapse occurrences between baseline and follow-up, that is, episodes resulting in admission and/or any case-note records of re-emergence of positive psychotic symptoms. The expected number of recruited patients is about 400, and that of relatives about 300. Owing to the implementation of the intervention at the CMHC level, the blinding of patients, clinicians, and raters is not possible, but every effort will be made to preserve the independency of the raters. We expect that this study will generate evidence on the best treatments for FEP, and will identify barriers that may hinder its feasibility in ‘real-world’ clinical settings, patient/family conditions that may render this intervention ineffective or inappropriate, and clinical, psychological, environmental, and service organization predictors of treatment effectiveness, compliance, and service satisfaction. Trial registration ClinicalTrials.gov Identifier NCT01436331

We report a case of a pseudoaneurysm of the common hepatic artery treated with a stent-graft in a 67-year-old man. The patient presented with severe catheter bleeding through a drain following surgical and interventional procedures performed for therapeutic management of a choledochal cholangiocarcinoma. Selective hepatic arteriography showed a pseudoaneurysm close to the origin of the gastroduodenal artery. After a preliminary attempt at arterial embolization, it was decided to use a stent-graft to bridge the false aneurysm. Complete pseudoaneurysm exclusion was seen after the procedure with preservation of hepatic arterial flow.

A 64-year-old woman developed acute Reiter's syndrome 4 weeks after the start of intravesical Bacillus Calmette-Guerin immunotherapy for a recurrent superficial bladder carcinoma. The absence of any other cause suggests that the bacillus played an etiopathogenic role in this HLA-B27-positive patient.