Leo Moro

Endothelial Dysfunction in Chronic Obstructive Pulmonary Disease

Background: Cardiovascular diseases are prevalent in people with chronic obstructive pulmonary disease (COPD). We hypothesized that endothelial dysfunction could be a marker of the proatherogen status in COPD. Methods and results: We measured endothelial dysfunction by flow-mediated dilation (FMD) and after sublingual administration of nitroglycerin (nitrate-mediated dilation: NMD) in 44 COPD patients and 48 controls. Compared with controls COPD patients had worse mean FMD (5.4% vs 8.2%, P < .001) and NMD (12.0% vs 13.9%, P = .007). FMD was inversely related to FEV1/VC ratio (r = −0.327, P = .030). The negative association between COPD and FMD was confirmed after correction for potential confounders in a multiple linear regression model (β = −0.019, P = .002). In the same model NMD (β = 0.396, P < .001) was positively associated with FMD. Conclusions: Endothelial-dependent and, to a lesser extent, endothelial-independent dilations are significantly impaired in COPD, and the impairment is proportional to the severity of bronchial obstruction.

Effect of local and remote ischemic preconditioning on endothelial function in young people and healthy or hypertensive elderly people.

To verify whether age affects remote preconditioning, we compared healthy young people (mean age = 28.0 years, SD: 7.2), healthy elderly people (age = 69.2 years, SD: 5.0), and hypertensive elderly people (group 3, age = 72.8 years, SD: 3.9). Each group included 10 participants. The flow-mediated-dilation (FMD) was measured after local (same arm) and remote (leg) ischemic preconditioning. Healthy elderly people had the greatest increase of FMD after ischemic preconditioning compared to baseline (173% after local and 181% after remote preconditioning) and young participants the smallest increase (77% after local and 69% after remote preconditioning) while hypertensive elderly had an intermediate increase (P for comparison across groups: 0.347 for local and 0.064 for remote preconditioning). However, absolute values of FMD after preconditioning were much lower in elderly hypertensive than in healthy young adults. Remote preconditioning increases endothelial reactivity in healthy and hypertensive elderly. The potential clinical relevance of this finding deserves consideration.

Patients with migraine with aura have increased flow mediated dilation

BackgroundEndothelium-derived nitric oxide (NO) mediates the arterial dilation following a flow increase (i.e. flow-mediated dilation, FMD), easily assessed in the brachial artery. NO is also involved in cerebral hemodynamics and it is supposed to trigger vascular changes occurring during migraine. This study aimed at investigating whether migraine patients present an altered response to NO also in the peripheral artery system.MethodsWe enrolled 21 migraineurs (10 with aura [MwA], 11 without aura [MwoA]), and 13 controls. FMD was evaluated with ultrasound in all subjects by measuring the percentage increase of the brachial artery diameter induced by hyperaemia reactive to sustained cuff inflation around the arm above systolic pressure. FMD values were then normalized for shear stress.ResultsNormalized FMD values were higher in patients with MwA (28.5 10-2%.s) than in controls (9.0 10-2%.s) and patients with MwoA (13.7 10-2%.s) (p < 0.001). FMD was over the median value (19%) in 23.1% of controls, in 45.5% of the MwoA patients, and in 90% of the MwA patients.ConclusionsMigraineurs with aura present an excessive arterial response to hyperaemia, likely as an effect of an increased sensitivity to endothelium-derived nitric oxide. This phenomenon observed peripherally might reflect similar characteristics in the cerebral circulation.

Dilution of a mepivacaine-adrenaline solution in isotonic sodium bicarbonate for reducing subcutaneous infiltration pain in ambulatory phlebectomy procedures: A randomized, double-blind, controlled trial

BACKGROUND Varicose veins are treated under local infiltration anesthesia. Literature shows that adding sodium bicarbonate reduces the pain associated with local infiltration anesthesia. Nonetheless, sodium bicarbonate is underused. OBJECTIVE We sought to assess if the use of a solution of mepivacaine 2% plus adrenaline with sodium bicarbonate 1.4% results in less pain associated with local infiltration anesthesia preceding ambulatory phlebectomies, compared with standard preparation diluted with normal saline. METHODS In all, 100 adult patients undergoing scheduled ambulatory phlebectomy were randomized to receive either a solution of mepivacaine chlorhydrate 2% plus adrenaline in sodium bicarbonate 1.4% or a similar solution diluted in normal saline 0.9%. RESULTS Median pain scores associated with local infiltration anesthesia reported in the intervention and control groups were 2 (SD=1.6) and 5 (SD=2.0) (P<.0001), respectively. A general linear model with bootstrapped confidence intervals showed that using the alkalinized solution would lead to a reduction in pain rating of about 3 points. LIMITATIONS Patients were not asked to distinguish the pain of the needle stick from the pain of the infiltration. Moreover, a complete clinical study of sensitivity on the infiltrated area was not conducted. CONCLUSIONS Data obtained from this study may contribute to improve local infiltration anesthesia in ambulatory phlebectomy and other phlebologic procedures.

The Foot Venous System: Anatomy, Physiology and Relevance to Clinical Practice

OBJECTIVE This review aims to summarize present knowledge of foot venous return, with a special interest in clinical and research implications. METHODS It is based on the latest available publications on foot anatomy and hemodynamics. MATERIALS ANATOMY: Five systems are described: the superficial veins of the sole, the deep veins of the sole (with particular attention to the lateral plantar vein), the superficial dorsal plexus, the marginal veins and the dorsal arch and the perforating system. The Foot Pump: The physiology of venous return is briefly described, with an emphasis on the differences between standing and walking and the interplay of the foot and calf venous systems. RESULTS The hypothesis that the foot and calf venous systems may be in conflict in several clinical conditions (localization of leg ulcers, corona phlebectatica, foot vein dilatation, arteriovenous fistulas of the foot, foot‐free bandaging) is presented, briefly discussed, and mechanistically interpreted. CONCLUSIONS Foot venous return could be more important than is commonly thought. Certain clinical conditions could be explained by a conflict between the mechanisms of the foot pump and the leg pumps most proximal to the foot, rather than by generic pump insufficiency, with possible effects on treatment and compression strategies.

Metabolic syndrome and impaired lung function.

We read with great interest the recent article in CHEST (October 2009) 1 by Watz and colleagues showing an independent association between metabolic syndrome and systemic infl ammatory markers in chronic bronchitis and patients with COPD. The authors also demonstrate that the prevalence of metabolic syndrome does not increase for increasing COPD severity, as expressed by the Global Initiative for Chronic Obstructive Lung Disease stage. Interestingly, metabolic syndrome is also associated with a restrictive ventilatory pattern at spirometry, especially in patients with the highest waist circumference. 2 In this population, visceral fat is known to produce prothrombotic and infl ammatory mediators, including C-reactive protein, fi brinogen, interleukin-6, and tumor necrosis factora . Since lung restriction is frequently associated with systemic infl ammation independent of obesity, the infl ammatory burden due to restriction may add to that related to visceral obesity in patients having both diseases. 3 For this reason we believe that the authors should have provided information on the prevalence of a mixed ventilatory pattern in their population instead of classifying patients only on the basis of the FEV 1 FVC ratio and FEV 1 %. This would have required the measurement of total lung capacity. Nonetheless, based on the available data, it would be of interest at least to know how prevalent was a spirometric pattern suggesting a restrictive component, which is known to be associated with systemic infl ammation. 4 Indeed, recent evidence is consistent with an FVC based on presumptive diagnosis of lung restriction being comparably accurate in people with and without obstruction. 5 Finally, the authors provide the Charlson index of comorbidity, but they do not list individual comorbidities and their prevalences; selected conditions, such as renal failure, could per se promote systemic infl ammation. Providing such information would allow the authors and the readers to verify whether the infl ammatory pattern changes for different combinations of COPD, a restrictive component and visceral obesity. Otherwise, the authors might ascribe to COPD an infl ammatory status, which in a relevant proportion of patients likely is multifactorial in origin.

Catastrophic Antiphospholipid Syndrome Presenting With Multiorgan Failure and Gangrenous Lesions of the Skin

A 38-year-old woman with a 20-year history of systemic lupus erythematosus and positive anticardiolipin antibodies developed anuria and hypotension. 20 days before, she had discontinued 25 mg prednisone, but not warfarin, on medical advice. 3 days before admission, she developed extensive necrosis and blisters involving both arms and legs and a multiorgan failure. She improved after immunosuppressive and antibiotic therapy, 3 sessions of dialysis and 5 sessions of plasmapheresis. It was decided that she could be discharged after 45 days. Her skin lesions were complicated by several abscesses requiring surgical drainage and finally healed almost completely within 9 months. Catastrophic antiphospholipid syndrome is a distinctly rare dramatic condition characterized by widespread thrombosis of small vessels, which in the present case was likely triggered by the abrupt withdrawal of steroid therapy. It should be borne in mind in cases of multiorgan failure, which does not recognize a well-defined etiology.

Association of peripheral venous disease with arterial endothelial dysfunction: a proof-of-concept study

The objective of the study was to evaluate the association between peripheral venous disease (PVD) and arterial endothelial dysfunction (ED). Arterial and venous diseases have been always considered as two completely different entities, but the recent discovery of a relationship between arterial and venous thrombosis have challenged this assumption. ED, considered to be an early process in the pathophysiology of atherosclerotic disease, could represent a common pathogenetic background. We studied 39 healthy volunteers (median age: 34 years; men: 25.6%). PVD was diagnosed using ultrasound examination, arterial ED using flow-mediated dilation (FMD) and FMD normalized for the peak shear rate (nFMD). Compared with controls, participants with PVD had a lower FMD (15.2 versus 23.4%, P < 0.001) and nFMD 12.7 ×10 –3 versus 19 × 10–3/second, P < 0.001 . People with the most clinically evident disease had the worst endothelial function. In conclusion, our findings, if confirmed in larger population, might corroborate the idea that venous and arterial disease could have common causes.

Foot-sparing postoperative compression bandage: a possible alternative to the traditional bandage.

Objectives: To verify whether a foot-sparing bandage is effective for patients who have undergone varicose vein surgery, being in the C2 class, having a normal deep venous system and actively walking. Methods: Ninety consecutive lower legs meeting the inclusion criteria underwent treatment with an inelastic foot-sparing bandage. Patients satisfaction, efficacy and local effects were systematically documented. Results: The bandage was well tolerated and highly effective. Four of the first 20 cases experienced a slight morning oedema of the foot, which disappeared while walking. Thus, in the remaining cases we covered the foot and distal limb with a custom short tubular-shaped ‘sock’ providing 10 mmHg compression, only during the first 24 hours. Conclusion: The foot-sparing inelastic bandage is effective, cheap and tolerated by well-selected patients who have undergone varicose vein surgery.

Valsalva maneuver in phlebologic practice

Forced expiration against an airway obstruction was originally described as a method for inflating the Eustachian tubes and is accredited to Antonio Maria Valsalva (1666–1723). The Valsalva maneuver is commonly applied for different diagnostic purposes. Its use for phlebologic diagnosis is the object this review. Venous reflux is the most frequent pathophysiologic mechanism in chronic venous disease. Reflux is easily visualized by duplex ultrasound when properly elicited, in standing position. A simple way to elicit reflux is the so-called “compression-release maneuver”: by emptying the muscle reservoir, it determines a centrifugal gradient, dependent on hydrostatic pressure, creating an aspiration system from the superficial to the deep system. The same results are obtained with dynamics tests activating calf muscles. The Valsalva maneuver elicits reflux by a different mechanism, increasing the downstream pressure and, thus, highlighting any connection between the source of reflux and the refluxing vessel. The Valsalva maneuver is typically used to investigate the saphenofemoral junction. When the maneuver is performed correctly, it is very useful to analyse several conditions and different hemodynamic behaviours of the valvular system at the saphenofemoral junction. Negative Valsalva maneuver always indicates valvular competence at the saphenofemoral junction. Reverse flow lasting during the whole strain (positive Valsalva maneuver) indicates incompetence or absence of proximal valves. Coupling Valsalva maneuver to compression-release maneuver, with the sample volume in different saphenofemoral junction sections, may reveal different hemodynamic situations at the saphenofemoral junction, which can be analysed in detail.