Raffaella Motta

Adrenal vein sampling for primary aldosteronism: the assessment of selectivity and lateralization of aldosterone excess baseline and after adrenocorticotropic hormone (ACTH) stimulation.

Background Adrenal vein sampling is crucial for identifying the primary aldosteronism subtypes, but the cutoff values for ascertaining selectivity of catheterization and lateralization of aldosterone secretion remain controversial. Objectives To investigate the safety of adrenal vein sampling, the cutoff values for the selectivity and lateralization indexes, and the effect of adrenocorticotropic hormone stimulation on selectivity index and lateralization index performance. Design We assessed the proportion of selective adrenal vein sampling at different selectivity index cutoff values in 151 consecutive patients with primary aldosteronism undergoing bilaterally simultaneous adrenal vein sampling. Aldosterone-producing adenoma was diagnosed on the basis of the evidence of primary aldosteronism and lateralized aldosterone secretion, adenoma at pathological examination, and normokalemia, and correction of primary aldosteronism and cure or improvement of hypertension at follow-up. In 44 patients with bilaterally selective adrenal vein sampling and unequivocal diagnosis of aldosterone-producing adenoma on the basis of all these criteria, we examined the cutoff values of the lateralization index for assessing the lateralization of aldosterone excess and the effect of adrenocorticotropic hormone stimulation on selectivity index and lateralization index. Results Adrenal vein rupture occurred in one case (0.7%). Bilaterally selective adrenal vein sampling decreased steadily (from 79.9 to 40.2%) with increase in the selectivity index cutoffs from 1.1 to 5.0. Likewise, the proportion of correctly identified aldosterone-producing adenomas decreased (from 95.5 to 43.2%) with increase in lateralization index cutoffs from 1.125 to 5.0. Adrenocorticotropic hormone improved the assessment of selectivity but exerted a confounding effect on lateralization index. Conclusion Adrenal vein sampling is safe; increasing the selectivity index cutoffs lowers the number of usable adrenal vein samplings; higher lateralization index cutoff values lead to missing a proportion of aldosterone-producing adenomas. The improved selectivity rate provided by adrenocorticotropic hormone stimulation should be weighed against the loss of correct lateralization.

Impact of Accessory Hepatic Veins on Adrenal Vein Sampling for Identification of Surgically Curable Primary Aldosteronism

Adrenal vein sampling is the gold standard for identification of surgically curable primary aldosteronism, but its accuracy might be hindered by blood dilution from accessory vein blood. We prospectively investigated the presence of accessory veins draining into adrenal veins and their effect on the selectivity index (SI) in 74 consecutive patients undergoing adrenal vein sampling. On the right side, the venous anatomic pattern could be conclusively determined in 91.8% of the cases: we detected hepatic accessory veins in 12.1%, no accessory veins in 42.4%, and renal capsular veins in 45.5%. On the left side there was a phrenico-adrenal trunk in 89.4% and renal capsular accessory veins in 10.6% of the cases. On both sides, renal capsular and phrenic accessory veins did not affect the SI. At variance, on the right side, hepatic accessory veins were associated with SI values ≈3-fold lower than that found when such accessory veins were absent (median: 3.10 [range: 0.80 to 84.2] versus median: 1.10 [range: 0.70 to 2.20]; P=0.01). However, superselective adrenal catheterization resulted into higher SI values (median: 23.88; range: 4.80 to 84.20) in these cases. Thus, hepatic accessory veins sharing egress into the inferior vena cava with the right adrenal vein occurred in ≈12% of the patients and imply a low SI, likely because of adrenal blood dilution by hepatic blood carrying a low cortisol concentration. In the presence of this anatomic variation, superselective catheterization of the right adrenal vein should be undertaken to determine the lateralization of aldosterone secretion.

A stress reaction affects assessment of selectivity of adrenal venous sampling and of lateralization of aldosterone excess in primary aldosteronism

BACKGROUND A stress reaction involving increased cortisol release, which has not been documented thus far, might affect the assessment of selectivity of catheterization during adrenal venous sampling (AVS). OBJECTIVE To investigate whether an ACTH-driven cortisol release occurs during AVS and whether it influences the assessment of selectivity by the step-up of cortisol (plasma cortisol concentrations, PCC) between the adrenal vein blood (PCC(SIDE)) and the inferior vena cava (PCC(IVC)), e.g. the selectivity index (SI). DESIGN AND METHODS We determined the SI in samples obtained simultaneously at starting AVS (t-15) and again after 15  min (t0) in 34 consecutive patients with proven aldosterone-producing adenoma. We then calculated the SI with PCC(SIDE) obtained at t-15 and at t0, and the PCC(IVC) values obtained at the different time point, thus simulating sequential AVS. RESULTS The PCC(SIDE) and the SI fell significantly from t-15 to t0 on both the sides. When PCC(SIDE) obtained at t-15 was combined with PCC(IVC) at t0, the SI values were higher than those obtained with simultaneously drawn samples. This led to label as selective more AVS studies than with bilaterally simultaneous data, especially when using higher cutoffs for the SI. CONCLUSIONS A transient increase in cortisol release from both adrenal glands occurs in the majority of the patients who undergo AVS. This stress reaction can influence the assessment of both the selectivity of the catheterization during the sequential AVS technique and the lateralization of aldosterone excess.

Minimally invasive surgical options in pediatric heart surgery.

Surgery for congenital heart disease has changed considerably during the last decade. Improved surgical results in patients with simple congenital heart disease and new interventional cardiology procedures have stimulated the surgeon to adopt minimally invasive techniques with the aim of reducing the patient’s surgical insult and obtaining good functional and cosmetic results. As a consequence, new surgical techniques and special equipment for minimally invasive heart procedures have been developed and refined in recent years. This article reports on our institutional protocols for minimally invasive surgery in children and adults with congenital heart disease.

The Medical and Endovascular Treatment of Atherosclerotic Renal Artery Stenosis (METRAS) study: rationale and study design.

It is unclear whether revascularization of renal artery stenosis (RAS) by means of percutaneous renal angioplasty and stenting (PTRAS) is advantageous over optimal medical therapy. Hence, we designed a randomized clinical trial based on an optimized patient selection strategy and hard experimental endpoints. Primary objective of this study is to determine whether PTRAS is superior or equivalent to optimal medical treatment for preserving glomerular filtration rate (GFR) in the ischemic kidney as assessed by 99mTcDTPA sequential renal scintiscan. Secondary objectives of this study are to establish whether the two treatments are equivalent in lowering blood pressure, preserving overall renal function and regressing target organ damage, preventing cardiovascular events and improving quality of life. The study is designed as a prospective multicentre randomized, un-blinded two-arm study. Eligible patients will have clinical and angio–CT evidence of RAS. Inclusion criteria is RAS affecting the main renal artery or its major branches either >70% or, if <70, with post-stenotic dilatation. Renal function will be assessed with 99mTc-DTPA renal scintigraphy. Patients will be randomized to either arms considering both resistance index value in the ischemic kidney and the presence of unilateral/bilateral stenosis. Primary experimental endpoint will be the GFR of the ischemic kidney, assessed as quantitative variable by 99TcDTPA, and the loss of ischemic kidney defined as a categorical variable.

Asymmetry and Structure of the Fronto-Parietal Networks Underlie Visuomotor Processing in Humans

Abstract Research in both humans and monkeys has shown that even simple hand movements require cortical control beyond primary sensorimotor areas. An extensive functional neuroimaging literature demonstrates the key role that cortical fronto‐parietal regions play for movements such as reaching and reach‐to‐grasp. However, no study so far has examined the specific white matter connections linking the fronto‐parietal regions, namely the 3 parallel pathways of the superior longitudinal fasciculus (SLF). The aim of the current study was to explore how selective fronto‐parietal connections are for different kinds of hand movement in 30 right‐handed subjects by correlating diffusion imaging tractography and kinematic data. We showed that a common network, consisting of bilateral SLF II and SLF III, was involved in both reaching and reach‐to‐grasp movements. Larger SLF II and SLF III in the right hemisphere were associated with faster speed of visuomotor processing, while the left SLF II and SLF III played a role in the initial movement trajectory control. Furthermore, the right SLF II was involved in the closing grip phase necessary for efficient grasping of the object. We demonstrated for the first time that individual differences in asymmetry and structure of the fronto‐parietal networks were associated with visuomotor processing in humans.

An investigation of the neural circuits underlying reaching and reach-to-grasp movements: from planning to execution

Experimental evidence suggests the existence of a sophisticated brain circuit specifically dedicated to reach-to-grasp planning and execution, both in human and non-human primates (Castiello, 2005). Studies accomplished by means of neuroimaging techniques suggest the hypothesis of a dichotomy between a “reach-to-grasp” circuit, involving the anterior intraparietal area, the dorsal and ventral premotor cortices (PMd and PMv – Castiello and Begliomini, 2008; Filimon, 2010) and a “reaching” circuit involving the medial intraparietal area and the superior parieto-occipital cortex (Culham et al., 2006). However, the time course characterizing the involvement of these regions during the planning and execution of these two types of movements has yet to be delineated. A functional magnetic resonance imaging study has been conducted, including reach-to-grasp and reaching only movements, performed toward either a small or a large stimulus, and Finite Impulse Response model (Henson, 2003) was adopted to monitor activation patterns from stimulus onset for a time window of 10 s duration. Data analysis focused on brain regions belonging either to the reaching or to the grasping network, as suggested by Castiello and Begliomini (2008). Results suggest that reaching and grasping movements planning and execution might share a common brain network, providing further confirmation to the idea that the neural underpinnings of reaching and grasping may overlap in both spatial and temporal terms (Verhagen et al., 2013). But, although responsive for both actions, they show a significant predominance for either one of the two actions and such a preference is evident on a temporal scale.

Role of multidetector CT angiography and contrast-enhanced ultrasound in redefining follow-up protocols after endovascular abdominal aortic aneurysm repair

PurposeContrast-enhanced ultrasonography (CEUS) is an appealing alternative to computed tomography angiography (CTA) for the follow-up of patients who underwent endovascular abdominal aortic aneurysm repair (EVAR). We sought to evaluate the accuracy of CEUS compared with a particularly tailored protocol of CTA performed with a 64-row multidetector CT.Materials and methodsThe study prospectively enrolled 88 consecutive patients for CEUS and CTA imaging during follow-up after EVAR, yielding 142 paired examinations. The outcome is represented by three main goals: identification and characterisation of endoleaks, evaluation of graft patency and measurement of aneurysm diameter. Triple-phase CTA was the gold standard.ResultsSensitivity and specificity of CEUS compared with CTA in endoleak and graft patency evaluation were 91.89% and 100% and 72% and 100%, respectively. A very high correlation between CTA and CEUS diameter measurements was established. CEUS did not appear superior to CTA in endoleak detection, probably because a tailored CTA protocol with a delayed phase (180 s) allows detection of low-flow endoleaks.ConclusionsPatient management was not different stafollowing CEUS and CTA results. CTA cannot yet be completely replaced, but several limitations (radiation exposure, contrast agent) encourage redefining the routine follow-up imaging modality. We suggest an algorithm of surveillance alternating CTA and CEUS.RiassuntoObiettivoL’ecografia con mezzo di contrasto (CEUS) rappresenta una valida alternativa all’angio-tomografia computerizzata (CTA) nel follow-up dei pazienti sottoposti a trattamento endovascolare di aneurisma aortico addominale (EVAR). Abbiamo voluto valutare l’accuratezza di CEUS confrontata con CTA eseguita con apparecchio multidetettore a 64 strati e protocollo specifico.Materiali e metodiLo studio prospettico ha arruolato 88 pazienti consecutivi indagati con CEUS e CTA durante il follow-up post-EVAR, ottenendo 142 esami appaiati. Sono stati considerati tre parametri: identificazione e caratterizzazione degli endoleak, valutazione della pervietà della protesi, misura del diametro aneurismatico. La CTA trifasica costituiva il gold-standard.RisultatiSensibilità e specificità di CEUS versus CTA nella valutazione di endoleak e pervietà endoprotesica sono state 91,89% e 100%, 72% e 100%, rispettivamente. Si è ottenuta una correlazione molto elevata tra le due metodiche nella misurazione dei diametri. CEUS non è apparsa superiore a CTA nell’identificazione degli endoleak, probabilmente grazie al protocollo mirato comprendente la fase tardiva (180 s), che permette di riconoscere anche leak tardivi a basso flusso.ConclusioniLa gestione dei pazienti non sarebbe cambiata seguendo i risultati CEUS e CTA. Attualmente CTA non può essere completamente sostituita, ma importanti limiti impongono di ridefinire il follow-up strumentale post-EVAR: proponiamo un algoritmo che alterni CEUS e CTA.

The overlap syndrome between primary biliary cirrhosis and primary sclerosing cholangitis

BACKGROUND The overlap syndrome between primary biliary cirrhosis and primary sclerosing cholangitis is an extremely rare condition that has been reported in only six published cases so far. METHODS Here we report two cases showing the clinical manifestations of both primary biliary cirrhosis and primary sclerosing cholangitis. RESULTS In one case the overlap condition was associated with psoriatric arthritis, and the patient successfully underwent dual treatment with ursodeoxycholic acid and the anti-tumour necrosis factor-alpha agent adalimumab. In the second case, the predominant condition was, initially, an antimitochondrial antibody-negative primary biliary cirrhosis with progressive course towards end-stage liver disease; the patient then developed either antimitochondrial antibody positivity or changes in the biliary tree compatible with primary sclerosing cholangitis. CONCLUSIONS These two cases add information on a controversial issue in the literature, and indicate the importance of recognizing a possible overlap syndrome to optimize treatment.

The role of the frontal aslant tract and premotor connections in visually guided hand movements

Abstract Functional neuroimaging and brain lesion studies demonstrate that secondary motor areas of the frontal lobe play a crucial role in the cortical control of hand movements. However, no study so far has examined frontal white matter connections of the secondary motor network, namely the frontal aslant tract, connecting the supplementary motor complex and the posterior inferior frontal regions, and the U‐shaped dorsal and ventral premotor fibers running through the middle frontal gyrus. The aim of the current study is to explore the involvement of the short frontal lobe connections in reaching and reach‐to‐grasp movements in 32 right‐handed healthy subjects by correlating tractography data based on spherical deconvolution approach with kinematical data. We showed that individual differences in the microstructure of the bilateral frontal aslant tract, bilateral ventral and left dorsal premotor tracts were associated with kinematic features of hand actions. Furthermore, bilateral ventral premotor connections were also involved in the closing grip phase necessary for determining efficient and stable grasping of the target object. This work suggests for the first time that hand kinematics and visuomotor processing are associated with the anatomy of the short frontal lobe connections. HighlightsHand kinematics is associated with the anatomy of the short frontal lobe connections.Frontal aslant and premotor tracts are related to variation in motor performance.Ventral premotor tract is associated with closing grip phase of grasping.