Aterosclerosi il danno d'organo: vasculopatia periferica - di P. Buonamico. 7 giugno 2012. Corso di formazione "valore nutrizionale e salutistico di prodotti agroalimentari” - Università degli studi di Bari.
Systemic Hypertension (HTN) accounts for the largest amount of attributable Cardiovascular (CV) mortality worldwide. There are several factors responsible for the development of HTN and its CV complications. Multicenter trials revealed that risk factors responsible for Micro Vascular Disease (MVD) are similar for those attributable to Coronary Artery Disease (CAD) which include tobacco use, unhealthy cholesterol levels, HTN, obesity and overweight, physical inactivity, unhealthy diet, diabetes, insulin resistance, increasing age and genetic predisposition. In addition, the defective release of Nitric Oxide (NO) could be a putative candidate for HTN and MVD. This study reviewed the risk stratification of hypertensive population employing cardiac imaging modalities which are of crucial importance
in diagnosis. It further emphasized the proper used of cardiac imaging to determine patients at increased CV risk and identify the management strategy. It is now known that NO has an important effect on blood pressure, and the basal release of endothelial Nitric Oxide (eNOS) in HTN may be reduced. Although there are different forms of eNOS gene allele, there is no solid data revealing the potential role of the polymorphism of the eNOS in patients with HTN and coronary vascular diseases. In the present article, the prevalence of eNOS G298 allele in hypertensive patients with micro vascular angina will be demonstrated. This review provides an update on appropriate and justified use of non-invasive imaging tests in hypertensive patients and its important role in proper diagnosis of MVD and CAD. Second, eNOS gene allele and its relation to essential hypertension and angina pectoris are also highlighted.
Role of Left Ventricular Mass Index Versus Left Ventricular Relative Wall Thi...Premier Publishers
In non-cardioembolic stroke patients, the cardiac manifestations of elevated blood pressure are of particular interest. The value of LV geometry in the prediction of cardiovascular risk is controversial. Many reports detected that left ventricular hypertrophy is independently associated with risk of ischemic stroke. The primary objective of this study was to identify the frequency of different patterns of altered left ventricular geometry in patients with non cardioembolic stroke, and to assess whether a significant number of patients will miss the diagnosis of LV remodeling if the left ventricular relative wall thickness(RWT) is not evaluated or reported. 100 patients were referred within 48 hours after an acute non cardioembolic ischemic stroke for a transthoracic echocardiogram. The echocardiographic findings were analyzed. Mean age was 61.86 ± 12.59 years, 45 % men. Concentric remodeling carried the highest frequency (43%), followed by normal pattern (27%), concentric hypertrophy (22%), and eccentric hypertrophy (8%). The frequency of abnormal left ventricular RWT (61.4%) was significantly higher than that of abnormal LVMI.
PERIPHERAL ARTERIOPATY AND DIABETES: EPIDEMIOLOGY, DIAGNOSIS AND THERAPEUTIC PATH
ARTERIOPATIA PERIFERICA E DIABETE: EPIDEMIOLOGIA, EZIOPATOGENESI, DIAGNOSI E PERCORSO TERAPEUTICO
(Angiologia-Chirurgia Vascolare-ULSS 15 Alta Padovana)
(Angiology-Vascular Surgery-ULSS 15 Alta Padovana)
Systemic Hypertension (HTN) accounts for the largest amount of attributable Cardiovascular (CV) mortality worldwide. There are several factors responsible for the development of HTN and its CV complications. Multicenter trials revealed that risk factors responsible for Micro Vascular Disease (MVD) are similar for those attributable to Coronary Artery Disease (CAD) which include tobacco use, unhealthy cholesterol levels, HTN, obesity and overweight, physical inactivity, unhealthy diet, diabetes, insulin resistance, increasing age and genetic predisposition. In addition, the defective release of Nitric Oxide (NO) could be a putative candidate for HTN and MVD. This study reviewed the risk stratification of hypertensive population employing cardiac imaging modalities which are of crucial importance
in diagnosis. It further emphasized the proper used of cardiac imaging to determine patients at increased CV risk and identify the management strategy. It is now known that NO has an important effect on blood pressure, and the basal release of endothelial Nitric Oxide (eNOS) in HTN may be reduced. Although there are different forms of eNOS gene allele, there is no solid data revealing the potential role of the polymorphism of the eNOS in patients with HTN and coronary vascular diseases. In the present article, the prevalence of eNOS G298 allele in hypertensive patients with micro vascular angina will be demonstrated. This review provides an update on appropriate and justified use of non-invasive imaging tests in hypertensive patients and its important role in proper diagnosis of MVD and CAD. Second, eNOS gene allele and its relation to essential hypertension and angina pectoris are also highlighted.
Role of Left Ventricular Mass Index Versus Left Ventricular Relative Wall Thi...Premier Publishers
In non-cardioembolic stroke patients, the cardiac manifestations of elevated blood pressure are of particular interest. The value of LV geometry in the prediction of cardiovascular risk is controversial. Many reports detected that left ventricular hypertrophy is independently associated with risk of ischemic stroke. The primary objective of this study was to identify the frequency of different patterns of altered left ventricular geometry in patients with non cardioembolic stroke, and to assess whether a significant number of patients will miss the diagnosis of LV remodeling if the left ventricular relative wall thickness(RWT) is not evaluated or reported. 100 patients were referred within 48 hours after an acute non cardioembolic ischemic stroke for a transthoracic echocardiogram. The echocardiographic findings were analyzed. Mean age was 61.86 ± 12.59 years, 45 % men. Concentric remodeling carried the highest frequency (43%), followed by normal pattern (27%), concentric hypertrophy (22%), and eccentric hypertrophy (8%). The frequency of abnormal left ventricular RWT (61.4%) was significantly higher than that of abnormal LVMI.
PERIPHERAL ARTERIOPATY AND DIABETES: EPIDEMIOLOGY, DIAGNOSIS AND THERAPEUTIC PATH
ARTERIOPATIA PERIFERICA E DIABETE: EPIDEMIOLOGIA, EZIOPATOGENESI, DIAGNOSI E PERCORSO TERAPEUTICO
(Angiologia-Chirurgia Vascolare-ULSS 15 Alta Padovana)
(Angiology-Vascular Surgery-ULSS 15 Alta Padovana)
Aterosclerosi e danno d’organo: - di P. BuonamicoMedOliveOil
Il danno d’organo: l’aterosclerosi - di P. Buonamico. 5 giugno 2012. Corso di formazione "valore nutrizionale e salutistico di prodotti agroalimentari” - Università degli studi di Bari.
To learn more about diabetic foot wounds visit my website
www.healmyfootwoundfast.com
Educational power point on foot wounds relating to:
1. Obesity in America
2. The Epidemic of Diabetes
3. Complications of Diabetes
4. Cost Realities of Diabetes
5. Chronic Foot Ulcers
Dr. Donald Pelto
299 Lincoln Street Suite 202
Worcester, MA 01605
Methods: The current clinical study was conducted at Gaza city. It involved 90 patients who were scheduled for coronary angioplasty procedure. The patients were divided into three groups: The first group (n = 30), underwent BMS implantation and received colchicine 0.5 mg twice daily for six months. The second group (n = 30), underwent BMS implantation alone. The third group (n = 30) underwent DES implantation. All the patients were followed up for six months. The primary endpoint was clinical ISR at 6months. Secondary endpoints included Target Vessel Revascularization (TVR) and Stent Thrombosis (ST).
carotid stenosis is a progressive gradual narrowing of carotid artery resulting in TIA and stroke. managemnet of this is challenging owing to various factors and different management options available to choose from.
Correlation Between ECG Changes and 2D Speckle Tracking Echocardiography with...Premier Publishers
The clinical presentation of acute coronary syndrome is variable Patients with suspected NSTE-ACS are a heterogeneous group. Coronary occlusion may or may not be present. To correlate 2D speckle tracking echocardiography with coronary angiography results in non-ST segment elevation myocardial infarction patients and test its ability to predict culprit lesion. It is a prospective study where 100 patients with non-ST elevation myocardial infarction were enrolled in the study where regional wall motion score index was obtained by echocardiography then 2D speckle tracking echocardiography was done and territorial longitudinal strain for each vessel was obtained and finally coronary angiography was done. By using the bull’s eye view of the territorial LS values obtained from the 17 myocardial segments to predict the culprit artery for each patient the sensitivity for prediction of culprit LAD was 93.3 %, specificity was 92.7 %, For LCX; sensitivity was 82.7 %, specificity was 92.9 % and for RCA; sensitivity was 84 %, specificity was 93.3 %. Longitudinal strain imaging by 2D speckle-tracking might help in the work-up of non-ST elevation myocardial infarction patients. In addition, it may be helpful to localize coronary artery stenosis in a given perfusion territory.
Impact of statins and beta-blocker therapy on mortality after coronary artery...Paul Schoenhagen
Background: We conducted a retrospective cohort study of patients after first-time isolated coronary artery bypass graft surgery (CABG) and assessed the impact of a discharge regimen including beta-blockers and statin therapy and their relationship to long-term all cause mortality and major adverse cardiovascular events (MACE).
Methods: We identified patients age >18 years, undergoing first time isolated CABG from 1993 to 2005. Patients were identified using the Cardiovascular Information Registry (CVIR). We collected follow-up information at 30, 60, 90 days and yearly follow-up. The registry is approved for use in research by the institutional review broad.
Results: We identified 5,205 patients who underwent single isolated CABG between January 1993 and December 2005. The mean age was 64.5±9.7 years and over 70% were male. There was a significant difference in the low density lipoproteins (LDL) concentration between those with or without statin medications (134±41.9 mg/dL) (no statin) vs. 126±44.8 mg/dL (with statin), P=0.001. A discharge regimen with statin therapy was associated with and overall reduction in 30 day, 1 year and long-term mortality. In addition, overall the triple ischemic endpoint of death, myocardial infarction (MI) and stroke was also significantly lower in the statin vs. no-statin group. In addition, statin and beta-blockers exerted synergistic effect on overall mortality outcomes short-term and in the long-term. We note that the predictors of overall death include no therapy with statin therapy and age [hazard ratios (HR) 1.1, 95% CI: 1.04-1.078, P<0.001] and presence of renal failure (HR 2.0, P=0.005). The estimated 11-year Kaplan Meier curves for mortality between the two groups starts to diverge immediately post discharge after single isolated CABG and continue to diverge through out the follow-up period.
Conclusions: A post-discharge regimen of statins independently reduces overall and 1 year mortality. These results confirm those of earlier studies within a contemporary surgical population and support the current clinical guidelines.
Impact of statins and beta-blocker therapy on mortality after coronary artery...Paul Schoenhagen
Abstract
Background: We conducted a retrospective cohort study of patients after first-time isolated coronary artery bypass graft surgery (CABG) and assessed the impact of a discharge regimen including beta-blockers and statin therapy and their relationship to long-term all cause mortality and major adverse cardiovascular events (MACE).
Methods: We identified patients age >18 years, undergoing first time isolated CABG from 1993 to 2005. Patients were identified using the Cardiovascular Information Registry (CVIR). We collected follow-up information at 30, 60, 90 days and yearly follow-up. The registry is approved for use in research by the institutional review broad.
Results: We identified 5,205 patients who underwent single isolated CABG between January 1993 and December 2005. The mean age was 64.5±9.7 years and over 70% were male. There was a significant difference in the low density lipoproteins (LDL) concentration between those with or without statin medications (134±41.9 mg/dL) (no statin) vs. 126±44.8 mg/dL (with statin), P=0.001. A discharge regimen with statin therapy was associated with and overall reduction in 30 day, 1 year and long-term mortality. In addition, overall the triple ischemic endpoint of death, myocardial infarction (MI) and stroke was also significantly lower in the statin vs. no-statin group. In addition, statin and beta-blockers exerted synergistic effect on overall mortality outcomes short-term and in the long-term. We note that the predictors of overall death include no therapy with statin therapy and age [hazard ratios (HR) 1.1, 95% CI: 1.04-1.078, P<0.001] and presence of renal failure (HR 2.0, P=0.005). The estimated 11-year Kaplan Meier curves for mortality between the two groups starts to diverge immediately post discharge after single isolated CABG and continue to diverge through out the follow-up period.
Conclusions: A post-discharge regimen of statins independently reduces overall and 1 year mortality. These results confirm those of earlier studies within a contemporary surgical population and support the current clinical guidelines.
Antonietta Pascalone - L’olio extravergine d’oliva: un bene prezioso per la s...MedOliveOil
Tesina a cura della dott.ssa Antonietta Pascalone - Corso di formazione "valore nutrizionale e salutistico di prodotti agroalimentari” - Università degli studi di Bari luglio 2012
Raffaella Trentadue - Valutazione nutrizionale e salutistico di prodotti agro...MedOliveOil
Tesina a cura della dott.ssa Raffaella trentadue - Corso di formazione "valore nutrizionale e salutistico di prodotti agroalimentari” - Università degli studi di Bari luglio 2012
Massimo Cassanelli - Valutazione nutrizionale e salutistico di prodotti agroa...MedOliveOil
Tesina a cura del dott. Massimo Cassanelli - Corso di formazione "valore nutrizionale e salutistico di prodotti agroalimentari” - Università degli studi di Bari luglio 2012
Pellegrino Mariangela - Analisi chimica dei costituenti minori degli oli extr...MedOliveOil
Tesina a cura del dott. Fabrizio Bossis - Corso di formazione "valore nutrizionale e salutistico di prodotti agroalimentari” - Università degli studi di Bari luglio 2012
Maria Angela Cascarano - Composizione chimica dell'olio extravergine di oliva MedOliveOil
Tesina a cura del dott.ssa Maria Angela Cascarano - Corso di formazione "valore nutrizionale e salutistico di prodotti agroalimentari” - Università degli studi di Bari luglio 2012
Paola Zanna - Effetti biochimici e salutistici dell'olio d'oliva MedOliveOil
Tesina a cura del dott.ssa Paola Zanna - Corso di formazione "valore nutrizionale e salutistico di prodotti agroalimentari” - Università degli studi di Bari luglio 2012
Giuliano Gattoni - Valutazione nutrizionale e salutistico di prodotti agroali...MedOliveOil
Tesina a cura del dott. Giuliano Gattoni - Corso di formazione "valore nutrizionale e salutistico di prodotti agroalimentari” - Università degli studi di Bari luglio 2012
Francesca Nanna - Costituenti minori caratterizzanti e valore nutrizionale e...MedOliveOil
Tesina a cura della dott.ssa Francesca Nanna - Corso di formazione "valore nutrizionale e salutistico di prodotti agroalimentari” - Università degli studi di Bari, luglio 2012
Fabrizio Bossis - Composizione chimica dei costituenti minori dell'olio extr...MedOliveOil
Tesina a cura del dott. Fabrizio Bossis - Corso di formazione "valore nutrizionale e salutistico di prodotti agroalimentari” - Università degli studi di Bari luglio 2012
Storia della Dieta Mediterranea - di Michele ZonnoMedOliveOil
Storia della Dieta Mediterranea - di Michele Zonno. 5 giugno 2012. Corso di formazione "valore nutrizionale e salutistico di prodotti agroalimentari” - Università degli studi di Bari.
Stili di vita mediterraneo e sindrome metabolica - di Michele ZonnoMedOliveOil
Stili di vita mediterraneo e sindrome metabolica - di Michele Zonno. 28 giugno 2012. Corso di formazione "valore nutrizionale e salutistico di prodotti agroalimentari” - Università degli studi di Bari.
La dieta mediterannea e salute - di Michele ZonnoMedOliveOil
La dieta mediterannea e salute - di Michele Zonno. 6 giugno 2012. Corso di formazione "valore nutrizionale e salutistico di prodotti agroalimentari” - Università degli studi di Bari.
La dieta mediterannea - di Michele ZonnoMedOliveOil
La dieta mediterannea - di Michele Zonno. 4 giugno 2012. Corso di formazione "valore nutrizionale e salutistico di prodotti agroalimentari” - Università degli studi di Bari.
Costituenti chimici dell'olio - di A. SgargamellaMedOliveOil
Costituenti chimici dell'olio - di A. Sgargamella. 26 giugno 2012. Corso di formazione "valore nutrizionale e salutistico di prodotti agroalimentari” - Università degli studi di Bari.
Casi Clinici 2 - Prof. Sasso. 27 giugno 2012. Corso di formazione "valore nutrizionale e salutistico di prodotti agroalimentari” - Università degli studi di Bari.
Casi Clinici 1 - del Prof. Sasso. 27 giugno 2012. Corso di formazione "valore nutrizionale e salutistico di prodotti agroalimentari” - Università degli studi di Bari.
La Sindrome Cardiometabolica - di Stefania PuglieseMedOliveOil
La Sindrome Cardiometabolica - di Stefania Pugliese. 25 giugno 2012. Corso di formazione "valore nutrizionale e salutistico di prodotti agroalimentari” - Università degli studi di Bari.
La promozione degli stili di vita - di Vincenzo Ostilio PalmieriMedOliveOil
Promozione degli stili di vita - di Vincenzo Ostilio Palmieri. 14 giugno 2012. Corso di formazione "valore nutrizionale e salutistico di prodotti agroalimentari” - Università degli studi di Bari.
Diet treatment in liver cirrhosis - di Vincenzo Ostilio PalmieriMedOliveOil
Dieta nella cirrosi epatica - di Vincenzo Ostilio Palmieri. 21 giugno 2012. Corso di formazione "valore nutrizionale e salutistico di prodotti agroalimentari” - Università degli studi di Bari.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
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Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
3. Etiopatogenesi E SM
Insulino Resistenza
•Ridotta produzione insulino-indotta di ossido nitrico (NO)
(antiaterogenica)
Nessuna influenza sulla crescita e migrazione dei
miociti, insulino dipendente, che è invece aterogena.
•Potenziata produzione angiotensina II stimolata da
Plasminogen activator inhibitor-1 (PAI-1) che può contribuire
ad un effetto pro-trombotico.
•Ridotta sensibilità del muscolo scheletrico all’insulina (per cui
ne deriva vasocostrizione ed ipertensione)
Fagan TC Am J Med 1988
7. Imt e Aterotrombosi
Stabilizzazione delle lesioni
• Ridotta vulnerabilità della placca:
– Riduzione del core lipidico o cambiamento della sua composizione;
– Riduzione della concentrazione di macrofagi o dell'attività di degrado della
matrice;
– Aumento densità SMC e sintesi di matrice.
• Ridotta trombogenicità della placca:
– Riduzione core lipidico;
– Riduzione densità dei macrofagi e contenuto/attività del tissue factor;
• Aumentata funzionalità endoteliale:
– Ripristino funzioni vasodilatatorie normali;
– Ridotto fenotipo protrombotico;
• Eliminazione di fattori estrinseci che favoriscono la rottura della placca
8.
9. MISURA US
Pignoli P, Tremoli E, Poli A, Oreste P, Paoletti R. Intimal plus medial
thickness of the arterial wall: a direct measurement with ultrasound
imaging. Circulation 1986
10.
11.
12.
13.
14. Misurazione IMT
Intimal plus medial thickness of the arterial wall: a direct
measurement with ultrasound imaging. Pignoli P, Tremoli E,
Poli A, Oreste P, Paoletti R. Circulation. 1986 Dec;74(6):1399-406.
A study in vitro of specimens of human aortic and common carotid arteries
was carried out to determine the feasibility of direct measurement (i.e., not
from residual lumen) of arterial wall thickness with B mode real-time imaging.
Measurements in vivo by the same technique were also obtained from common
carotid arteries of 10 young normal male subjects. Aortic samples were
classified as class A (relatively normal) or class B (with one or more
atherosclerotic plaques). In all class A and 85% of class B arterial samples a
characteristic B mode image composed of two parallel echogenic lines
separated by a hypoechoic space was found. The distance between the two
lines (B mode image of intimal + medial thickness) was measured and
correlated with the thickness of different combinations of tunicae evaluated by
gross and microscopic examination. On the basis of these findings and the
results of dissection experiments on the intima and adventitia we concluded
that results of B mode imaging of intimal + medial thickness did not differ
significantly from the intimal + medial thickness measured on pathologic
examination.
15. Among " emergent" risk factor ,
hyperhomocisteinemia , stress, standing at work …
seems to be linked with an increase of intima media
thickness.
16.
17.
18. • Baseline CCA-IMT is an independant predictor of
carotid plaque occurrence ( EVA Study ) with a
prevalence of plaque threfold higher in the subject
with high IMT at baseline (7) .
20. IMT e Rischio cardiovascolare
• L’IMT dell’arteria carotide comune e della
carotide interna è associata con il rischio di Stroke
e di infarto miocardico (IMA) in pazienti anziani
asintomatici (> 65 anni). Il rischio relativo per
IMA e Stroke tra la minore e la maggiore IMT è
3.87 (cardiovacular health study), con follow up
mediano di 6.2 anni.
• O'Leary et al.Carotid artery intima and media thickness as a risk factor for
myocardial infarction and stroke in older adults. Cardiovascular Health Study
Collaboration Research Group. N Engl J Med 1999 Jan7;340(1):14-22
21.
22.
23.
24. Misura IMT
• In pratica va misurata sulla carotide comune
a partire da un centimetro al di sotto della
biforcazione (carotide comune) e al di sopra
di questa (carotide interna).
• Vanno misurate entrambe le pareti
prossimale e distale.
25. Correlazione dell’IMT con la
coronaropatia
Grobbee DE, Bots ML. Carotid artery intima-media thickness as an
indicator of generalized atherosclerosis. J Intern Med 1994; 236: 567–573
Hodis HN, Mack WJ, LaBree L, Selzer RH, Liu CR, Liu CH, et al. The
role of carotid arterial intima-media thickness in predicting clinical
coronary events. Ann Intern Med 1998; 128: 262–269
26. • S Coccheri and G Palareti: The cardiovascular risk burden of
intermittent claudication
Eur. Heart J. Suppl., March 1, 2002; 4(suppl_B): B46 - B49.
• P.M. Rothwell: The Interrelation between carotid, femoral and
coronary artery disease
Eur. Heart J., January 1, 2001; 22(1): 11 - 14.
• S. Cuomo, et al :Increased carotid intima-media thickness in children-
adolescents, and young adults with a parental history of premature
myocardial infarction
Eur. Heart J., 2002; 23(17): 1345 - 1350
• J. Luedemann, et al : Association Between Behavior-Dependent
Cardiovascular Risk Factors and Asymptomatic Carotid
Atherosclerosis in a General Population
Stroke, 2002; 33(12): 2929 - 2935.
27. S. Cuomo, et al :Increased carotid intima-media thickness in children-
adolescents, and young adults with a parental history of premature
myocardial infarctionEur. Heart J., 2002; 23(17): 1345 - 1350
• Conclusions Vascular structural changes associated
with a parental history of premature myocardial
infarction are already detectable in childhood and
adolescence and occur independently of several
traditional cardiovascular risk factors.
• (mean of combined sites: age 5–18 years:
0·45±0·076mm vs 0·40±0·066mm in controls,
P=0·008; age 19–30 years: 0·48±0·077mm vs
0·45±0·078mm in controls,P =0·007)
28. Association Between Behavior-Dependent Cardiovascular Risk Factors and
Asymptomatic Carotid Atherosclerosis in a General Population (Luederman J,
stroke 2002)
• Conclusions— Physical activity and optimal
diet are associated with reduced risk of early
atherosclerosis in subjects who never smoked,
while no benefit of an otherwise optimal
lifestyle is observed in smokers.
•
29. Prevalence and Relation to Ambulatory Blood Pressure in a Middle-
aged General Population in Northern Italy: The Vobarno Study M. L.
Muiesan, et al. Hypertension. 1996;27:1046-1052.
• Prevalence of intima-media thickening (intima-media
thickness >1 mm) was 11% in normotensive subjects and
44% in hypertensive subjects. The presence of plaque
(wall thickening with either mineralization or focal
protrusion in the lumen at least 50% greater than the
surrounding wall, usually >2 mm) was observed in 35% of
normotensive subjects and 44% of hypertensive subjects.
The prevalence of left ventricular hypertrophy was 13% in
normotensive subjects and 19% in hypertensive subjects
30. Prevalence and Relation to Ambulatory Blood Pressure in a Middle-
aged General Population in Northern Italy: The Vobarno Study M. L.
Muiesan, et al. Hypertension. 1996;27:1046-1052.
• Intima-media thickness in the common and bifurcation segments of
carotid arteries correlated well with LVMI (r=.20 and r=.19,
respectively; P<.01). Intima-media thickness and LVMI were both
positively related to 24-hour monitored BP (P<.01). However, in the
multivariate analysis, body mass index (P=.027), sex (P<.001), and
24-hour mean BP (P=.025) were the most significant determinants of
LVMI, whereas carotid artery intima-media thickness was found to be
associated best with age (P<.001), cigarette smoking (P=.009), serum
cholesterol (P=.025), serum glucose (P=.038), and nighttime systolic
BP (P=.006). Logistic regression analysis confirmed the association
between the presence of plaque and age (P<.001), nighttime systolic
BP (P<.05), and cigarette smoking (P<.05);
31. Prevalence and Relation to Ambulatory Blood Pressure in a Middle-
aged General Population in Northern Italy: The Vobarno Study M. L.
Muiesan, et al. Hypertension. 1996;27:1046-1052.
• a negative association between plaque and the decrease in
mean systolic BP from daytime to nighttime was also
observed (P<.001). In conclusion, in a general population
of unselected middle-aged subjects, carotid wall thickness
and LVMI were associated with each other and related to
24-hour BP levels although the major determinants of
carotid wall and cardiac structure were different.
•
32.
33.
34. IMT E FATTORI DI RISCHIO CV
• There is a strong association with various risk
factor for atherosclerosis.
Arterial wall thickening has a strong pronostic
value for cardiovascular events , in particular
stroke and myocardial infarction.
• IMT allows convenient stratification of patients at
risk for cardiovascular disease and has proved to
be a good marker of the efficacity of
antiatherogenic driugs.
• The ease and accuracy of computer -assisted IMT
measurement makes it a useful marker of
cardiovascular involvement in atherosclerosis.
35. CONCLUSIONI
• Forte associazione con vari fattori di rischio per
aterosclerosi (classici ed emergenti)
• Valore prognostico per eventi cardiovascolari- Stroke
e infarto miocardico.
• IMT = buon marker per l’effcacia di farmaci
antiaterogenici
• Notevole sensibilità per la stratificazione di pazienti
ad alto rischio per malattia cardiovascolare.
36. Stenosi Carotidea
Cosa significa
Stenosi carotidea significativa?
Emodinamicamente = > 50%
Clinicamente ?
37.
38.
39. TIA (VA CSP 309) Symptomatic PTS
(ECST) (NASCET)
Carotid endarterectomy symptomatic
stenosis >70% ipsilateral stroke/crescendo Carotid endarterectomy symptomatic Carotid endarterectomy symptomatic
stenosis >70% ipsilateral stroke stenosis >70% Ipsilateral stroke
5000 pts follow up 5 aa Mayo clinic
2518 pts 3 yars foolw up 662 pts five years follow up mean 2.7 y
41. •
ACAS TRIAL
1662 patients from more than 42 000
• 39 centers in North America between 1987 and 1993.
• age 40 to 79 year.
• Significant stenosis = 60% reduction in diameter by arteriography,
• Patients assigned to surgery then underwent preoperative cerebral arteriography.
• Arteriography was not mandatory in the medical arm, but 319 (37.5%) of the medical
patients had arteriography before randomization.
• NASCET Method (minimum residual lumen at the point of maximum stenosis referenced to
the diameter of the distal lumen of the internal carotid artery at the first point at which the
arterial walls became parallel).
• MEDICAL THERAPY : aspirin (325 mg/d)
• Primary end points included stroke and death, and those that occurred within 30 days
of surgery or 42 days (to account for the average of 12 days between randomization and
operation in the surgical arm)of medical randomization were considered perioperative.
42. ACAS trial
Asymptomatic carotid stenosis >60% Carotid endarterectomy asymptomatic
medical versus surgical therapy stenosis >60% relative risk reduction
43. 2295 pts 5 years follow up
medical treatment: aspirin or another anti-platelet
drug, treatment of hypertension, and advice to stop
smoking.
46. ACST (3120 pts >60% US Stenosis); Lancet 2004
• In summary, patients younger than 80 years old and without
• major comorbidities, with low surgical risk and with a moderate
• to severe asymptomatic carotid stenosis, have an increased risk
• of stroke or death over a period of 5 years of 12%. CEA in such
• a selected population produces a modest absolute risk reduction
• of 5% to 6% over medical therapy alone, which translates into
• approximately 50% relative risk reduction for stroke and death
• over a 5-years period if the perioperative risk is contained at less
• than 3%.
• These RCT also show that, contrary to symptomatic
• CEA studies, the risk of stroke and the benefit from CEA is not
• predicted by the degree of stenosis.
47. Doubts for Asymptomatic
This medical treatment is aimed at preventing stroke in any territory in the
previously asymptomatic patient (primary prevention) or preventing
recurrent stroke in a patient having suffered from either
a transient ischaemic attack (TIA) or previous stroke (secondary
prevention). In most cases, carotid endarterectomy will only prevent
stroke from the treated carotid stenosis. Medical treatment
has improved substantially since the randomised trials of surgery
versus medicine for carotid stenosis were completed. Hence,
particularly in asymptomatic patients, the thresholds for intervening
surgically or by endovascular treatment should almost
certainly be raised somewhat.
• Ederle J O, Brown MM, “The evidence for medicine versus surgery for carotid stenosis” European Journal of
Radiology 60(2006) 3–7.
48. Management of Carotid Stenosis
From the Division of Interventional Neurovascular Radiology and the Departments of
Radiology Neurology, Neurological Surgery, and Anesthesiology, University of California,
San Francisco, Medical Center, San Francisco. n engl j med 358;15, apr 2008
the 30-day rate of perioperative stroke or death was 1.1%, after exclusion
of the 1.2% rate-stroke from arteriography
• of Other strategies to treat this patient are possible, but none have been
shown to be as effective as carotid endarterectomy. The most
compelling
• alternative is intensive medical therapy with aggressive
• suppression of platelet function, targeted blood-pressure control
(possibly with the addition of beta-blockade and an angiotensin-
converting–
• enzyme inhibitor), and statin therapy. The argument
• has been made that the “best medical therapy” received by patients in
past clinical trials did not include widespread use of these current
therapies. This important question can be answered only by a proper
clinical trial comparing the two treatments. Until this is accomplished,
50. TACIT
TACIT (the Transatlantic Asymptomatic Carotid Intervention Trial),
controlled prospectic multicentric study, USA + Europe 2400 pts with
asymptomatic 70% carotid stenosis
• 3 branches : best medical therapy, BMT: terapia antiaggregante associata
• hypolipidemic. antihypertensive, glycemic and smoking control)
• vs BMT più EC vs
• BMT + stenting.
• Primary endpoint : evaluation and comparison of the peri –procedural risk off
stroke and death and at 3 yrs few secondary endpoints of which remarkable
is the effect on cognitive function.
55. Doppler flow measurement
Principle of blood flow measurement
US Doppler blood flow-meters
are based on the difference between the frequency of ultrasound
(US) waves emitted by the probe and those reflected (back-
scattered) by moving erythrocytes.
The frequency of reflected waves is (in comparison with the
emitted waves)
higher in forward blood flow (towards the probe)
lower in back blood flow (away from the probe)
The difference between the frequencies of emitted and reflected
US waves is proportional to blood flow velocity.
55
57. Doppler methods
Pulse wave (PW) systems
Aliasing – at high repetition frequency of pulses the upper part
of the spectral curve can appear in negative velocity range
- at velocity above 4m/s aliasing cannot be removed
Nyquist limit
57
58. Doppler flow measurement
∆F = 2 f x v x cos α ;
C
∆F = K x v x cos α
v = ∆F x K/ cos α
C = vel US nei tessuti
F = frequenza iniziale degli US
59. Doppler flow measurement
Dependence of velocity
overestimation on the incidence
angle α (if the device is adjusted
for
α = 0, i.e. cosα = 1)
α - angle made by axis of emitted US
beam and the velocity vector of the
reflector
59
60. Doppler flow measurementSystems
with pulsed wave - PW
1) Systems with continuous wave – CW. They are used for measurement on
superficial blood vessels. High velocities of flow can be measured, but without
depth resolution. Used only occasionally.
2) Systems with pulsed wave. It is possible to measure blood flow with accurate
depth localisation. Measurement of high velocities in depths is limited.
60
61. Doppler methods
DUPLEX method
is a combination
of dynamic B-mode imaging (the morphology of examined area
with blood vessels is depicted)
and the PW Doppler system (measurement of velocity spectrum
of blood flow).
It allows to examine blood flow inside heart or in deep blood
vessels (flow velocity, direction and character)
61
62. Doppler methods DUPLEX method
Scheme: sector image Image of carotid with spectral
with sampling volume analysis of blood flow velocity
62
63. Doppler methods
Pulse wave (PW) systems
Aliasing – at high repetition frequency of pulses the upper part
of the spectral curve can appear in negative velocity range
- at velocity above 4m/s aliasing cannot be removed
Nyquist limit
63
64. Doppler methods
Colour Doppler imaging
The image consists of black-white and colour part.
The black-white part contains information about reflectivity and
structure of tissues.
The colour part informs about movements in the examined
section. (The colour is derived from average velocity of flow.)
The apparatus depicts distribution and direction of flowing blood
as a two-dimensional image.
BART rule – blue away, red towards. The flow away from the
probe is coded by blue colour, the flow towards the probe is coded
by red colour. The brightness is proportional to the velocity,
turbulences are depicted by green patterns.
64
66. Doppler methods TRIPLEX method
A combination of duplex method (B-mode imaging with PW
Doppler) and color flow mapping
Normal finding of blood flow in a. carotis communis (left) and
about 90%-stenosis of a. carotis interna (right)
66
67. Doppler methods
POWER DOPPLER method
- the whole energy of the Doppler signal is utilised
- mere detection of blood flow only little depends on the
so-called Doppler incidence angle
- imaging of even very slow flows (blood perfusion of tissues and
organs)
- flow direction is not shown
67
75. Absolute velocity?
• Table I. Hemodynamic parameters described by Zwiebe111. and Strandness 12 for
duplex
• assessment of internal carotid artery stenosis
• Percent stenosis Zwiebel criteria Percent stenosis Strandness criteria
• 0-39 PSV < 110 cm/sec, EDV <40 crn/sec 1-15 No flow reversal in bulb
• 40-59 PSV < 130 cm/sec, EDV < 40 crn/sec 16-49 Spectral broadening
• 60-79 PSV > 130 cm/sec, EDV >40 crn/sec 50-79 PSV >25 cm/sec, EDV < 140
cm/sec
• 80-99 PSV > 250 cm/sec, EDV > 100 cm/sec 80-99 EDV > 140 cm/sec
• Occlusion No flow detected Occlusion No flow detected
• PSV, Peak systolic velocity; EDV, end diastofic velocity.
• *Zwiebel also describes the use of velocity ratios. Only the systolic velocity and end
diastolic velocity have been used here.
76.
77.
78. Reappraisal of duplex criteria to assess significant carotid stenosis with
special reference to reports from the North American Symptomatic Carotid
Endarterectomy Trial and the European Carotid Surgery Trial
ML. Neale, et al, j vasc surg 1994 20:642-9
• Conclusions: The accuracy of duplex studies
compared with angiography in the assessment
• of extracranial vascular disease depends on the
method of angiographic determination of
• carotid stenosis. Vascular laboratories should
validate the duplex criteria they use against
• a standard method of angiographic assessment of
carotid artery stenosis, with special reference to the
recently reported studies noting the significance of a
stenosis greater than 70% in patients with
symptoms. (J VAsc SURG 1994;20:642-9.)
86. Changes in area are not equal to
changes in diameter
• 2-1.4 cm = 70%
• 2- 1,4 = 0.6 cm D Area : 3.14 x 2
• 1x 1 x 3.14 =3.14
• 0.3 x 0.3 = 0.09 X
3.14 = 0.28
• 3.14 – 0.28 : 100 =
92%
87. Ultrasonography
Harmonic imaging
An impulse with basic frequency f0 is
emitted into the tissue. The receiver,
however, does not detect the reflected US
with this same frequency but with the second
harmonic frequency 2f0. Its source is tissue
itself (advantage in patients „difficult to
examine“). The method is also used with
echocontrast agents – source of the second
harmonic are oscillating bubbles.
Advantageous when displaying blood supply
of some lesions.
Conventional (left) and
harmonic (right) images
of a kidney with a stone.
87
88. Ultrasonography
Echocontrast agents
- increase echogenity of streaming blood
Gas microbubbles
(mainly air or volatile
hydrocarbons)
- free
- enclosed in
biopolymer
envelope
A SEM micrograph of
encapsulated
echocontrast agent
88
90. Ultrasound pitfalls
• Carotid duplex ultrasound has several limitations:
• It is user dependent. If the duplex is not performed in a meticulous,
standardized and thorough fashion, results can be misleading.
• Heavy calcifications cause acoustic shadows that preclude
interpretation.
• Duplex ultrasound can not visualize the carotid arteries intracranially
or beyond the jaw. Visualization of the common carotid origin from
the Aorta is also difficult.
• PSV in tortuous vessels may be measured as high, thus mimicking
stenosis.
• Although duplex can characterize plaque according to various
characteristics, it has not been very successful in predicting which
plaque is more vulnerable to embolization. The same is true for carotid
artery imaging with CT and MR.
91. Transcranial ECD
.
Can U. Et Al Stroke. 1997 Oct;28(10):1966-71
the strongest indicators of a residual lumen diameter < 1.5 mm
• transorbital , :
• reversed flow in the ipsilateral ophthalmic artery (spec 100% S = 31%)
• a > 50% peak systolic velocity difference between the carotid siphons (distal ICAs) in patients
with unilateral ICA origin stenosis. (Spec 100% S 26% ) .
• transtemporal (no controlateral stenosis)
• in patients with a unilateral stenosis,
• > 35% difference in ipsilateral MCA PSV relative to the contralateral MCA. (SP 100/% S =
32%)
• > 50% difference in contralateral (ACA) PSV relative to the ipsilateral ACA. (SP 100%; S
43%).
• Irrespective of contralateral stenosis, a > 35% difference in ipsilateral MCA peak systolic velocity
relative to the ipsilateral PCA (Spec = 100% S = 23%)
• CONCLUSIONS:
• Although the TCD sensitivity for detecting a hemodynamically significant stenosis is relatively
low, it can be highly specific (up to 100%). We conclude that TCD enhances the specificity of
highly sensitive CDUS criteria for detecting a hemodynamically significant ICA stenosis.
99. Aneurismi
• Dissecante A o B
• Fusiformi o sacciformi (4.5 o 6 cm)
• Patologia stenosante congenita o acquisita
• (cong= coartazione aortica; acq. Leriche)
103. Vengono valutati tutti gli studi grandi emulticentrici
(DRASTIC, STAR, ASTRAL) che concludono tutti per una
scarsa efficacia globale dello stenting rispetto alla terapia
medica. Tutti gli studi hanno importanti lacune sul numero e
sulla metodologia (spesso stenosi non significative o creatinina
normale etc) E in corso lo studio CORAL (USA) che dovrebbe
essere più rigoroso.
104. 3. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA Guidelines
for the Management of Patients with Peripheral
Arterial Disease (Lower Extremity, Renal, Mesenteric,
and Abdominal Aortic): A Collaborative Report from the
American Association of Vascular Surgery/Society for
Vascular Surgery, Society for Cardiovascular Angiography
and Interventions, Society for Interventional Radiology,
Society for Vascular Medicine and Biology and the
American College of Cardiology/American Heart Associa-
105. Gli autori suggeriscono :
1)Stenosi di almeno il 70% all’angiografia o all’ultrasonografia intravascolare
2)ipertensione rapidamente instaurantesi, resistente a terapia o maligna.
3)Ipertensione rapida e d IRA in pts con stenosi bilaterale o monorene
4)Episodi di insufficienza cardiaca congestizia o edema polmonare
5)Intervento controindicato per IR (peak- end diastolic vel)/ peak elevati (>0.8)
107. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
DEFINIZIONE
LESIONI OSTRUTTIVE LOCALIZZATE A VALLE
DELLE ARTERIE RENALI CHE,
INDIPENDENTEMENTE DALLA LORO NATURA,
COMPORTANO UNA RIDUZIONE
DELLA PERFUSIONE DEGLI ARTI INFERIORI
108. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
CLASSIFICAZIONE
DIFFUSE
DEGENERATIVE
O ARTERIOSCLEROTICHE SEGMENTARIE
INFIAMMATORIE
NON DEGENERATIVE
INFETTIVE
110. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
NON DEGENERATIVE
MALATTIA DI HORTON
INFIAMMATORIE MALATTIA DI TAKAYASU
MALATTIA DI BUERGER
BATTERICHE (salmonelle, cocchi)
INFETTIVE VIRALI (influenza, herpes)
RICKETTSIE (burneti, moseri)
111. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
DEGENERATIVE
ATEROSCLEROSI
(ACCUMULO DI LIPIDI E STENOSI VASALE)
ARTERIOSCLEROSI
(ISPESSIMENTO INTIMALE DA MIGRAZIONE CELL.
MUSC. LISCE DELLA MEDIA SENZA ACCUMULO DI
LIPIDI)
SCLEROSI DELLA MEDIA DI MONCKEBERG
(DEGENERAZIONE CELLULE MUSCOLARI LISCE
E DEPOSIZIONE DI CALCIO NELLA MEDIA)
(ARTERIE MUSCOLARI DI MEDIO CALIBRO)
112. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
STADI CLINICI
FONTAINE NUOVA CLASSIFICAZIONE
I: PARESTESIE, IPOTERMIA
II: CLAUDICATIO INTERMITTENS ISCHEMIA RELATIVA
a) se maggiore di 200 m
b) se minore di 200 m
III: DOLORI A RIPOSO
ISCHEMIA CRITICA
IV: LESIONI TROFICHE, GANGRENA
113. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
CLAUDICATIO INTERMITTENS
DOLORE
CRAMPO
SINTOMO DESCRITTO COME:
STANCHEZZA
RIGIDITA’
INTERESSA SEMPRE I GRUPPI MUSCOLARI
SITUATI A VALLE DELLA LESIONE
PROVOCATO SEMPRE DALL’ATTIVITA’
SCOMPARE IN POCHI MINUTI CON IL RIPOSO
LA RIPRESA DELL’ATTIVITA’ PROVOCA IL DISTURBO
DOPO UNO STESSO PERCORSO E SEMPRE
CON LE STESSE CARATTERISTICHE
114. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
CLAUDICATIO INTERMITTENS
LOCALIZZAZIONE DEL DOLORE
LESIONE CLAUDICATIO
AORTO-ILIACA
GLUTEO
ILIACO-FEMORALE
COSCIA
FEMORO-POPLITEA
POLPACCIO
INFRA-POPLITEA
PIEDE
115. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
CARATTERIZZAZIONE CLAUDICATIO
SEDE
MODALITA’ D’INSORGENZA
AUTONOMIA DI MARCIA
TEMPO DI RECUPERO
RICOMPARSA ALLA RIPRESA DELL’ATTIVITA’
EVOLUZIONE NEL TEMPO
116. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
SEDE OSTRUZIONE ERRORE
ARTERIOSA Zona
DIAGNOSTICO
claudicatio
LOMBALGIA
AORTO-ILIACA ARTRITE DELL’ANCA
LOMBOSCIATALGIA
DISCOPATIA
ILIACO-FEMORALE MIOSITE
NEURITE LOMBARE
FEMORO-POPLITEA ARTRITE DEL GINOCCHIO
NEUROMA PLANTARE
INFRA-POPLITEA OSTEOPOROSI
NEUROPATIA DIABETICA
121. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
CIRCOLO COLLATERALE
OSTRUZIONE ARTERIA
ILIACA COMUNE DX
DISTRETTO
ARTERIOSO
NORMALE
RIABITAZIONE A VALLE
122. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
CIRCOLO COLLATERALE
OSTRUZIONE ARTERIA
FEMORALE COMUNE
RIABITAZIONE
BIFORCAZIONE FEMORALE
123. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
CIRCOLO COLLATERALE
OSTRUZIONE ARTERIA
FEMORALE SUPERFICIALE
RIABITAZIONE A VALLE
124. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
CIRCOLO COLLATERALE
STENO-OSTRUZIONI
MULTIPLE
ARTERIA
FEMORALE
SUPERFICIALE
OTTIMO CIRCOLO
COLLATERALE
128. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
DOLORE A RIPOSO
SI VERIFICA O SI ACCENTUA DI NOTTE
E’ PERSISTENTE TANTO DA IMPEDIRE IL SONNO
SI ATTENUA CON LA POSIZIONE ORTOSTATICA
129. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
DOLORE A RIPOSO
IMBIBIZIONE
INTERSTIZIO
> ESTRAZIONE O2 EDEMA
E METABOLITI
DIFFUSIONE O2
RISTAGNO SANGUE
E METABOLITI
PEGGIORAMENTO
ISCHEMIA
130. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
LESIONI ISCHEMICHE
GRAVE RIDUZIONE APPORTO EMATICO
INCAPACITA’ A
MANTENERE
METABOLISMO
NECROSI
TESSUTALE
LESIONE TROFICA (GANGRENA)
138. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
EVOLUZIONE CLINICA
A. FEMORALE SUPERFICIALE
PROGRESSIONE
LESIONE
STENOSI NON STENOSI
EMODINAMICHE EMODINAMICHE
139. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
EVOLUZIONE CLINICA
DISTRETTO AORTO-ILIACO
PROGRESSIONE
LESIONE
G. A. 3. 4. 71 G. A. 6. 12. 71
CLAUDICATIO DOLORI A RIPOSO
400 mt
140. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
EVOLUZIONE CLINICA
STENOSI POPLITEEE STENOSI POPLITEEE
NON EMODINAMICHE EMODINAMICHE
141. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
EVOLUZIONE CLINICA
PROGRESSIONE
LESIONE
OSTRUZIONE BIFORCAZIONE
AORTICA
(SINDROME DI LERICHE)
142. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
SINDROME DI LERICHE
DEFINIZIONE
OSTRUZIONE CRONICA DELLA BIFORCAZIONE
AORTICA AD ETIOLOGIA ARTERIOSCLEROTICA
CON TENDENZA DELLA TROMBOSI ALLA
PROGRESSIONE IN SENSO PROSSIMALE SINO
A COINVOLGERE L’ORIGINE DELLE ARTERIE
VISCERALI (RENALI, MESENTERICHE)
143. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
SINDROME DI LERICHE
ESAME OBIETTIVO
DISTROFIE CUTANEE E PERDITA ANNESSI
IPOTONIA E IPOTROFIA MASSE MUSCOLARI
ASSENZA BILATERALE POLSO FEMORALE
LESIONI TROFICHE (RARE)
144. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
SINDROME DI LERICHE
SINTOMATOLOGIA
CLAUDICATIO INTERMITTENS
A LUNGA AUTONOMIA DI MARCIA
(POLPACCIO, COSCIA E GLUTEO)
IMPOTENTIA ŒRIGENDI
ANGINA ABDOMINIS
INSUFFICIENZA RENALE ACUTA ED ANURIA
146. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
SINDROME DI LERICHE
CIRCOLI COLLATERALI
ARTERIE VISCERALI
A. PANCR.-DUODEN. SUP. A. PANCR.-DUODEN. INF.
(TRONCO CELIACO) (A. MESENTERICA SUP.)
ARCATA DI RIOLANO
A. COLICA MEDIA A. COLICA SINISTRA
(A. MESENTERICA SUP.) (A. MESENTERICA INF.)
ARCATA MARGINALE O DI DRUMMOND
A. MESENTERICA SUP. A. MESENTERICA INF.
(RAMI BORDO MESOCOLICO) (RAMI BORDO MESOCOLICO)
147. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
SINDROME DI LERICHE
CIRCOLI COLLATERALI
AORTO-IPOGASTRICI
VISCERALI
A. EMORROIDARIA SUP. A. EMORROIDARIA MEDIA
(A. MESENTERICA INF.) (A. MESENTERICA INF.)
A. OMBELICALE
A. SPERMATICA INTERNA A. VESCICOLO-DEFER.
A. OVARICA A. UTERINA
PARIETALI
A. INTERCOSTALI A. ILEOLOMBARE
A. LOMBARI A. GLUTEA SUP.
A. SACRALI LATERALI
A. SACRALE MEDIA A. PUDENDA INTERNA
148. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
SINDROME DI LERICHE
CIRCOLI COLLATERALI
AORTO-ILIACA ESTERNA, FEMORALE
VISCERALI
A. SPERMATICA INTERNA
STERNA
A. VESCICOLO-DEFEREN.
INF.)
(A. OMBELICALE)
PARIETALI
A. MAMMARIA INT. A. EPIGASTRICA INF.
A. INTERCOSTALI A. EPIGASTRICA SUPERF.
A. FRENICHE A. CIRCONFL. ILIACA PROF.
A. LOMBARI A. CIRCONFL. ILIACA SUPERF.
149. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
SINDROME DI LERICHE
CIRCOLI COLLATERALI
AORTO-ILIACA ESTERNA, FEMORALE
PARIETALI
A. OTTURATORIA A. EPIGASTRICA INFERIORE
A. ILEO-LOMBARE A. ILIACA ESTERNA
(RAMI M. PSOAS) (RAMI M. PSOAS)
A. PERINEALE SUPERF. A. PUDENDA ESTERNA
(A. PUDENDA INTERNA) (RAMI SCROTALI E LABIALI)
AA. CIRCONFLESSE ILIACHE
A. GLUTEA SUP.
(SUPERFICIALE E PROFONDA)
A. GLUTEA SUP. E INF. AA. CIRCONFLESSE FEMORALI
A. OTTURATORIA (MEDIALE E LATERALE)
A. PUDENDA INT. I, II, E III A. PERFORANTE
151. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
DIAGNOSI
CLINICA
ANAMNESI
ESAME OBIETTIVO
STRUMENTALE
NON INVASIVA
INVASIVA
152. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
DIAGNOSI CLINICA
ESAME OBIETTIVO
RE
ISPEZIONE TA I
LU TT TI
PALPAZIONE VA TU ET
TR
IS
PERCUSSIONE
ID
AUSCULTAZIONE
153. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
ESAME OBIETTIVO
ISPEZIONE
COLORE CUTE
TROFISMO ANNESSI CUTANEI
TROFISMO MASSE MUSCOLARI
PRESENZA LESIONI TROFICHE
154. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
ESAME OBIETTIVO
PALPAZIONE
TEMPERATURA CUTANEA
TROFISMO MASSE MUSCOLARI
EVENTUALI MASSE PULSANTI
VALUTAZIONE DEI POLSI
ARTI
COLLO
INFERIORI
ARTI SUPERIORI
RITMO ADDOME
CARDIACO
155. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
PALPAZIONE
POLSO FEMORALE
Due cm medialmente al punto medio tra spina
iliaca anteriore-superiore e tubercolo del pube
156. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
PALPAZIONE
POLSO POPLITEO
Lungo la bisettrice della losanga poplitea,
nel cavo popliteo
157. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
PALPAZIONE
POLSO TIBIALE POSTERIORE
Nella doccia retromalleolare mediale
158. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
PALPAZIONE
POLSO PEDIDIO
Lateralmente al tendine dell’estensore lungo dell’alluce
(molte variazioni anatomiche di decorso)
162. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
DIAGNOSI
CLINICA
ANAMNESI
ESAME OBIETTIVO
STRUMENTALE
NON INVASIVA
INVASIVA
163. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
DIAGNOSTICA STRUMENTALE
NON INVASIVA
DOPPLER
ECOCOLORDOPPLER
PLETISMOGRAFIA
RISONANZA MAGNETICA E ANGIO-RM
INVASIVA
ANGIOGRAFIA
TOMOGRAFIA COMPUTERIZZATA
164. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
DOPPLER
PERVIETA’ VASI
SEDE E GRAVITA’ LESIONI (DATO GROSSOLANO)
MISURAZIONE PRESSIONI DISTALI (I. W.)
COMPENSO EMODINAMICO (I. C. P. P.)
INDIRIZZO DIAGNOSTICO
165. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
DOPPLER
TERRITORIO AD ALTE RESISTENZE
1 ONDA SFIGMICA
1
2 ONDA REVERSE
3 SECONDA ONDA POSITIVA
3 4 RITORNO ALLA LINEA ZERO
4
2
ASSENZA DI
VELOCITOGRAMMA NORMALE FLUSSO DIASTOLICO
166. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
DOPPLER
TERRITORIO AD ALTE RESISTENZE
A
AUMENTO
PROGRESSIVO
DEL GRADO
DI LESIONE
H
VELOCITOGRAMMI PATOLOGICI
167. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
DOPPLER
RILEVAZIONI PRESSORIE
MISURAZIONE A VARI LIVELLI
(COSCIA, 1/3 SUPERIORE GAMBA, CAVIGLIA)
INDICE PRESSORIO O DI WINSOR PC
IW = ≥1
P. A. CAVIGLIA / P. A. OMERALE PO
(VALORE NORMALE ≥ 1)
INDICE DI COLLATERALITA’ PROFUNDO-POPLITEA
P. A. COSCIA – P. A. GAMBA / P. A. COSCIA
PC – PG
ICPP =
PC
168. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
ECOCOLORDOPPLER
ECODOPPLER
IMMAGINE ANATOMICA +
INFORMAZIONE FLUSSIMETRICA
SENSIBILITA’ 77-82%
SPECIFICITA’ 92-98%
ECOCOLORDOPPLER PER STENOSI
IMMAGINE DI FLUSSO DI > 50%
IMMEDIATA COMPRENSIONE
SENSIBILITA’ 76-92%
SPECIFICITA’ 93-99%
170. ARTERIOPATIA OSTRUTTIVA CRONICA
DEGLI ARTI INFERIORI
RISONANZA MAGNETICA E ANGIO-RM
VANTAGGI SVANTAGGI
ASSENZA DI INVASIVITA’ CLAUSTROFOBIA
O RISCHIO
VISUALIZZAZIONE VASI SOVRASTIMA STENOSI
E TESSUTO PERIVASALE
INFORMAZIONI NON ESEGUIBILE IN PAZIENTI
ANATOMO-FUNZIONALI CON PROTESI METALLICHE
GRANDE POTENZIALITA’ COSTI ELEVATI
(“TECNICA IDEALE”)
172. Messaggio Finale
• Eccetto il dubbio per trattare le stenosi
carotidee asintomatiche ( e gli aneurismi) ,
l’indicazione agli esami invasivi ed
all’eventuale terapia invasiva
(endovascolare o chirurgica) è guidata dal
sintomo (e/o dalla logica rischio-beneficio)