In a small percentage of cases with an occluded common carotid artery (CCA), the patency of the arteries beyond the carotid bulb is preserved. Color duplex sonography is useful for assessing blood flow in these vessels. We present a case of retrograde flow in an internal carotid artery (ICA) with an occluded ipsilateral CCA identified using color duplex sonography in a 70-year-old man with diabetes and known atherosclerotic disease. Color duplex sonography revealed that the right CCA was totally occluded near its origin and that flow was re-established at the bulb. Flow in the right ICA was directed cephalad, with a low-frequency, damped waveform; flow in the right external carotid artery (ECA) was bidirectional, with increased reversed diastolic flow. Extensive atherosclerotic lesions were also found in the left side. Endarterectomy of the left carotid bifurcation was performed. Follow-up color duplex sonography 3 months later revealed a small increase of stenosis in the left CCA and mild stenosis in the left ICA. The right CCA remained occluded, but reversed flow with a high-resistance flow pattern was seen in the ipsilateral ICA that supplied the ECA, which had cephalad-directed flow.

The HYPEDIA study aimed at evaluating the implementation of the 2018 European guidelines for treating hypertension in primary care. A nationwide prospective non-interventional cross-sectional study was performed in consecutive untreated or treated hypertensives recruited mainly in primary care in Greece. Participants’ characteristics, office blood pressure (BP) (triplicate automated measurements, Microlife BPA3 PC) and treatment changes were recorded on a cloud platform. A total of 3,122 patients (mean age 64 ± 12.5 [SD] years, 52% males) were assessed by 181 doctors and 3 hospital centers. In 772 untreated hypertensives (25%), drug treatment was initiated in the majority, with monotherapy in 53.4%, two-drug combination in 36.3%, and three drugs in 10.3%. Angiotensin receptor blocker (ARB) monotherapy was initiated in 30%, ARB/calcium channel blocker (CCB) 20%, ARB/thiazide 8%, angiotensin converting enzyme inhibitor (ACEi)-based 19%. Of the combinations used, 97% were in single-pill. Among 977 treated hypertensives aged <65 years, 79% had BP ≥ 130/80 mmHg (systolic and/or diastolic), whereas among 1,373 aged ≥65 years, 66% had BP ≥ 140/80 mmHg. ARBs were used in 69% of treated hypertensives, CCBs 47%, ACEis 19%, diuretics 39%, beta-blockers 19%. Treatment modification was decided in 53% of treated hypertensives aged <65 years with BP ≥ 130/80 mmHg and in 62% of those ≥65 years with BP ≥ 140/80 mmHg. Renin-angiotensin system blocker-based therapy constitutes the basis of antihypertensive drug treatment in most patients in primary care, with wide use of single-pill combinations. In almost half of treated uncontrolled hypertensives, treatment was not intensified, suggesting suboptimal implementation of the guidelines and possible physician inertia.

Sonography is not the method of choice for the evaluation of suspected peptic ulcer perforation (PUP). However, indirect sonographic signs and direct visualization of PUP have been reported by several authors in recent years. We report a case of an elderly woman who presented with severe abdominal pain and positive rebound sign, in whom abdominal sonography demonstrated indirect signs of PUP, the site of perforation, and active air fluid leakage through the perforated anterior prepyloric antral wall.

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