Doppler Waveform Analysis Research Articles

Evaluation of renal resistive index and new biomarkers in post-hepatitis C cirrhosis patients for developing kidney injury

Background In liver cirrhosis, hemodynamic changes in splanchnic and systemic circulations are involved. Indeed, no established laboratory markers for altered renal hemodynamics in cirrhosis were implicated. The duplex Doppler waveform analysis of intrarenal arteriolar vessels is considered a noninvasive estimate of renovascular impedance and renal arterial vasoconstriction. In particular, the renal resistive index (RRI) is considered as the best reliable indicator of renal blood flow in patients with different diseases. The study aimed to evaluate RRI, serum and urinary cystatin C, beta-trace protein, liver fatty acid protein, and kidney injury molecule-I as noninvasive indicators of altered renal hemodynamics in patients with cirrhosis with normal urea and creatinine. Patients and methods A case–control study included 60 patients with post-hepatitis C virus (HCV) cirrhosis and 40 healthy controls. Serum and urinary biomarkers were measured. Renal color Doppler duplex was used to evaluate RRI. Results Mean serum and urinary biomarkers in HCV patients were significantly higher than controls. Moreover, the RRI was higher in patients than in controls with P value less than 0.001. Rising levels of urea, high direct bilirubin, and hypoprothrombinemia with high serum kidney injury molecule 1 and RRI were significant independent predictors for subsequent kidney injury. Conclusion Urinary kidney injury molecule 1 is a reliable, sensitive, and specific biomarker for the prediction of kidney injury among HCV cirrhotic patients with an obvious superior test performance and specificity to e other biomarkers. An increase in serum kidney injury molecule 1 and RRI were associated with poor prognosis.

AMALRIC TRIANGULAR SIGN AND CAROTID DOPPLER ULTRASONOGRAPHIC FINDINGS IN CENTRAL RETINAL ARTERY OCCLUSION.

The aim of this study was to determine the incidence of the Amalric triangular sign (ATS) in patients with central retinal artery occlusion and investigate its association with visual function and carotid Doppler ultrasonography findings. A retrospective chart review was conducted on 21 eyes from 21 patients with complete central retinal artery occlusion. Best-corrected visual acuity and carotid Doppler ultrasonography findings [peak systolic velocity, end-diastolic velocity, and resistance index (RI) = (PSV - EDV)/PSV] were investigated. Three patients (14%) exhibited the ATS. Best-corrected visual acuity at first visit was significantly worse in ATS-positive patients than in ATS-negative patients (P = 0.024). Doppler waveform analysis of the common carotid artery showed that ATS-positive patients had a significantly lower end-diastolic velocity [P = 0.009, median 10 (range 9-10) vs. 17 (13-24) m/second] and significantly higher resistance index [P = 0.021, median 0.80 (range 0.79-0.83) vs. 0.72 (0.66-0.82)] than did ATS-negative. The Amalric triangular sign was observed in three patients with central retinal artery occlusion, who showed worse best-corrected visual acuity at the first visit than did those without the ATS. Carotid Doppler ultrasonography revealed that ATS-positive patients had a significantly higher resistance index and lower end-diastolic velocity at the common carotid artery than did ATS-negative, indicating steno-occlusive changes in the internal carotid artery.

Pulmonary vascular reactivity in growth restricted fetuses using computational modelling and machine learning analysis of fetal Doppler waveforms

The aim of this study was to investigate the pulmonary vasculature in baseline conditions and after maternal hyperoxygenation in growth restricted fetuses (FGR). A prospective cohort study of singleton pregnancies including 97 FGR and 111 normally grown fetuses was carried out. Ultrasound Doppler of the pulmonary vessels was obtained at 24–37 weeks of gestation and data were acquired before and after oxygen administration. After, Machine Learning (ML) and a computational model were used on the Doppler waveforms to classify individuals and estimate pulmonary vascular resistance (PVR). Our results showed lower mean velocity time integral (VTI) in the main pulmonary and intrapulmonary arteries in baseline conditions in FGR individuals. Delta changes of the main pulmonary artery VTI and intrapulmonary artery pulsatility index before and after hyperoxygenation were significantly greater in FGR when compared with controls. Also, ML identified two clusters: A (including 66% controls and 34% FGR) with similar Doppler traces over time and B (including 33% controls and 67% FGR) with changes after hyperoxygenation. The computational model estimated the ratio of PVR before and after maternal hyperoxygenation which was closer to 1 in cluster A (cluster A 0.98 ± 0.33 vs cluster B 0.78 ± 0.28, p = 0.0156). Doppler ultrasound allows the detection of significant changes in pulmonary vasculature in most FGR at baseline, and distinct responses to hyperoxygenation. Future studies are warranted to assess its potential applicability in the clinical management of FGR.

Effects of antenatal corticosteroids on fetal hemodynamics: a longitudinal study.

To study the effect of antenatal corticosteroid administration on fetal hemodynamics using longitudinal analysis of Doppler waveforms in the umbilical artery (UA) and middle cerebral artery (MCA). This was a retrospective study that included 30 fetuses at risk for preterm birth. Twenty-eight pregnant women were treated with betamethasone for fetal lung maturation. Doppler examinations of the UA and MCA were performed once before and three or eight times after corticosteroid administration. We used a Bayesian hierarchical linear model. Reference ranges were constructed, and associations between variables (gestational age and pre-eclampsia) were tested. The mean maternal age, gestational age at betamethasone administration, and gestational age at delivery were 32.6 ± 5.89 years, 30.2 ± 2.59 weeks, and 32.9 ± 3.42 weeks, respectively. On UA Doppler, there was a significant decrease in the pulsatility index (PI) after corticosteroid administration, with a mean of 0.1147 (credibility interval: 0.03687-0.191) in three observations and a median of 0.1437 (credibility interval: 0.02509-0.2627) in eight observations. However, there was no significant change in the Doppler MCA PI, regardless of gestational age and the presence or absence of pre-eclampsia. Although antenatal corticosteroid administration induced a significant decrease in the Doppler UA PI, we observed no change in the cerebral vasculature.

Improved Transcranial Doppler Waveform Analysis for Intracranial Hypertension Assessment in Patients with Traumatic Brain Injury.

Transcranial Doppler (TCD) is a noninvasive bedside tool for cerebral hemodynamic assessments in multiple clinical scenarios. TCD, by means of measuring systolic and diastolic blood velocities, allows the calculation of the pulsatility index (PI), a parameter that is correlated with intracranial pressure (ICP). Nevertheless, the predictive value of the PI for raised ICP appears to be low, as it is subjected to several, often confounding, factors not related to ICP. Recently, the pulsatile apparent resistance (PaR) index was developed as a PI corrected for arterial blood pressure, reducing some of the confounding factors influencing PI. This study compares the predictive value of PaR versus PI for intracranial hypertension (IH) (ICP > 20 mm Hg) in patients with traumatic brain injury. Patients with traumatic brain injury admitted to the neurocritical care unit who required invasive ICP monitoring were included prospectively within 5 days of admission. TCD measurements were performed in both middle cerebral arteries, allowing calculations of the PI and PaR. The optimal cutoff, discriminative power of these parameters for ICP ≥ 20 mm Hg, was assessed by calculating the area under the receiver operator characteristics curve (AUC). In total, 93 patients were included. A total of 20 (22%) patients experienced IH during the recording sessions. The discriminative power was low for PI (AUC 0.63) but slightly higher for PaR (AUC 0.77). Nonparametric analysis indicated significant difference for PaR when comparing patients with (median 0.169) and without IH (median - 0.052, p = 0.001), whereas PI medians for patients with and without IH were 0.86 and 0.77, respectively (p = 0.041). Regarding subanalyses, the discriminative power of these parameters increased after exclusion of patients who had undergone a neurosurgical procedure. This was especially true for the PaR (AUC 0.89) and PI (AUC 0.72). Among these patients, a PaR cutoff value of - 0.023 had 100% sensitivity and 52.9% specificity. In the present study, discriminative power of the PaR for discriminating IH was superior to the PI. The PaR seems to be a reliable noninvasive parameter for detecting IH. Further studies are warranted to define its clinical application, especially in aiding neurosurgical decision making, following up in intensive care units, and defining its ability to indicate responses according to the therapies administered.

ROLE OF DOPPLER ULTRASOUND AT 13 WEEKS GESTATION IN PREDICTION OF PRE-ECLAMPSIA

Objective: The objective of this study was to assess the role of Doppler ultrasound (USG) at 13-week gestation in the prediction of pre-eclampsia (PE) and to assess the mean pulsatility index (PI) in uterine arteries at 13-week Doppler ultrasonography for the early prediction of PE. Methods: This was a observational prospective cohort study in which all the pregnant females at 12–14 weeks gestation were subjected to Doppler waveform analysis on color Doppler USG machines. Obstetric parameters of fetal biometry, mean PI (using the TVS method), and percentiles were calculated using fetal medicine foundation proforma. Reports were categorized as high risk or low risk for the development of PE. Routine USG follow-up scanning was done at 18–20 weeks (Anomaly scan) 24–28 weeks (Growth scan) and 34–36 weeks (Doppler scan) for the development of PE and intrauterine growth restriction. Development or absence of PE was noted. Results: Four hundred antenatal patients were included in the study. The maximum number of patients was in the age group 21–30 years (75.50%). No significant difference in the occurrence of PE in different age groups was found in our study. The incidence of PE was 3.33% (1 out of 30) in patients who developed PE at a later stage. Similar incidence of hypertension was 10% (three out of 30), smoking, and diabetes in 2 and 3 each. The mean uterine artery PI level at 12–14 weeks was 3.11±0.12 in patients who developed PE. In our study, 24 (80%) high-risk (>1:150) and 10 (33.33%) low-risk (≤1:150) patients developed PE. Out of 30, 4 (13.33%) had Apgar 0–3, 6 (20%) had Apgar 4–6, and 20 (66.67%) had Apgar 7–10 in patients who developed PE. Conclusion: High mean uterine artery PI between 12 and 14 weeks gestation is a good predictor of PE and can be used as an effective screening tool. Diastolic notch in the uterine artery and combination of uterine artery Doppler parameters is better in the prediction of PE.

Prognostic value of Doppler waveform analysis of common femoral vein in septic patients: a prospective cohort study.

To assess whether there is an association between abnormal common femoral vein (CFV) Doppler waveform and intensive care unit (ICU) mortality in patients with sepsis. Patients admitted to the ICU with sepsis were included. Pulsed-wave Doppler was performed by examining the CFV in the short axis without angle correction and in the long axis with angle correction. An abnormal CFV Doppler waveform was determined by a retrograde velocity peak (RVP) > 10cm/s in the long axis or RVP > 50% of the antegrade velocity peak in the short axis. TAPSE < 17mm was defined as right ventricular (RV) dysfunction. The primary outcome was ICU mortality. One hundred and ten patients were included. There was no association between abnormal CFV Doppler waveforms in the long (p = 0.709) and short axes (p = 0.171) and ICU mortality. TAPSE measurements were performed in 16 patients. RV dysfunction was identified in 8 (50.0%) patients. There was no association between the diagnosis of RV dysfunction based on TAPSE measurement and the identification of abnormal CFV Doppler waveforms in the long axis (p = 1.000) and in the short axis (p = 1.000). Abnormal CFV Doppler waveforms were not associated with ICU mortality in patients with sepsis. Furthermore, in the exploratory analysis, these alterations were not useful in identifying RV dysfunction in these patients.

Carotid artery corrected flow time and respiratory variation of blood flow peak velocity for prediction of hypotension after induction of general anesthesia in adult patients undergoing emergency laparotomy for peritonitis: A prospective, observational study.

Doppler waveform analysis of carotid artery has been found to predict fluid responsiveness in patients undergoing elective surgeries. We evaluated the role of carotid artery corrected flow time (FTc) and respiratory variation of blood flow peak velocity (ðVpeak) in predicting post induction hypotension in patients undergoing emergency laparotomy for peritonitis. Adult patients (n = 60) with perforation peritonitis undergoing emergency laparotomy under general anesthesia (GA) were recruited in this prospective, observational study. Carotid ultrasonography was performed pre-induction, to determine FTc and ðVpeak. Post-induction hemodynamic parameters were recorded for 5 minutes. Spearman's rank correlation coefficient was used to determine the relationship between hypotension and carotid artery measurements. Post-induction hypotension occurred in 48.3% of patients. The carotid artery FTc was significantly lower (P = 0.008) in patients who developed post-induction hypotension, but ðVpeak was statistically similar (P = 0.62) in both groups. Spearman's rank correlation coefficient revealed a statistically significant correlation between FTc and systolic blood pressure (SBP) change at one-minute post induction (r2 = -0.29, P = 0.03); however statistical significance were not achieved at 2 minutes and 3 minutes (P = 0.05 at both time points). Carotid artery FTc had an area under the receiver operating characteristic (AUROC) curve (95% CI) of 0.70 (0.57-0.84) to predict post-induction hypotension and best cutoff value of 344.8 ms with a sensitivity and specificity of 61% and 79%, respectively. Carotid artery ðVpeak had an AUROC curve (95% CI) of 0.54 (0.39-0.69) to predict post-induction hypotension and best cutoff value of 7.9% with a sensitivity and specificity of 62% and 55%, respectively. Carotid artery FTc and ðVpeak are not reasonable predictors of hypotension in patients undergoing emergency laparotomy for perforation peritonitis.

Pitfalls in Carotid Doppler Interpretation and How to Avoid Them.

Imaging pitfalls commonly occur in carotid Doppler ultrasound and may lead to false positive diagnosis of stenosis, missed diagnosis of stenosis, and errors in grading stenosis severity. These pitfalls may result from suboptimal technique and/or patient-specific factors including coexisting cardiovascular pathology, contralateral high-grade stenosis/occlusion, tortuous vessels, tandem lesions, long-segment stenosis, nearly occlusive stenosis, and heavily calcified plaque. Awareness of these pitfalls and careful assessment of the extent of plaque on grayscale and color Doppler as well as analysis of the spectral Doppler waveforms can help avoid misinterpretation of the carotid Doppler examination.

The Impact of Diabetes in Intermittent Claudication: A Prospective Cohort Study.

The aim of this study was to determine the lower-limb outcome in patients with intermittent claudication (IC) and to identify predictors for deterioration. This study employed a prospective observational cohort single-centre design. One hundred fifty patients with IC attending a vascular surgery unit for the first time were recruited. Lower limb perfusion was assessed utilising ankle brachial index (ABI) measures, toe-brachial index (TBI) measures, Doppler waveform analysis and the walking impairment questionnaire. Follow-up was conducted after 1 year and 2 years following recruitment to assess haemodynamic parameters, symptom severity and outcome. Recruited participants had a mean age of 69.7 (±9.3) years, BMI 27.8(±4.2) and 79.3% were men. Significant haemodynamic decline (decline in ABPI by ≥0.15 and/or decline in TBPI by ≥0.1) occurred in 50.6% of the cohort within 2 years of whom 23.3% developed chronic limb threatening ischaemia (CLTI) with rest pain and/or tissue loss. Baseline ABPI, ABPI ≤ 0.5, TBPI ≤ 0.39, infrapopliteal artery (IPA) disease and high Haemoglobin A1c were identified as significant predictors for deterioration to CLI. (P < .05, binomial logistic regression). Patients with IC are at a high risk of developing CLTI within 2 years. Risk of lower limb adverse events is tripled in patients with IPA disease, low ankle and toe pressures and poorly controlled diabetes. Early identification of those at high risk for early deterioration may justify a paradigm shift in the management of this subgroup.

Congenital Syphilis Presenting with Brain Abnormalities at Neuroscan: A Case Report and a Brief Literature Review

A case of vertical transmission in a 35-year-old pregnant woman, gravida 4, para 2 with an unknown medical history of carrying primary syphilis is described. A routine 3rd trimester scan was performed at 30 + 5 weeks of pregnancy, which revealed fetal growth restriction (FGR) associated with absent fetal movement, a pathologic neuroscan characterized by cortical calcifications and ominous Doppler waveform analysis of the umbilical artery and ductus venosus. Computerized electronic fetal monitoring (EFM) showed a Class III tracing, according to the American College of Obstetricians and Gynecologists (ACOG) guidelines. An emergency C-section was performed and a female newborn weighing 1470 g was delivered. The Apgar scores were 5 and 8 at the first and fifth min, respectively. Besides the prompted obstetrical and neonatal interventions, the neonate died after 7 days. A histologic examination of the placenta revealed a chorioamnionitis at stage 1/2 and grade 2/3. The parenchyma showed diffuse delayed villous maturation, focal infarcts, and intraparenchymal hemorrhages. The decidua presented with chronic deciduitis with plasma cells. The parents declined the autopsy. Congenital syphilis is an emerging worldwide phenomenon and the multidisciplinary management of the mother and the fetus should be mandatory.

Doppler Waveform Analysis of Intertwin Venous Blood Flow in Twin Reversed Arterial Perfusion (TRAP) Sequence with a Rudimentary Heart.

Twin reversed arterial perfusion (TRAP) sequence is a rare anomaly in 1% of monochorionic twin pregnancies. Few TRAP sequence cases have a rudimentary heart with cardiac motion in the acardiac twins. Herein, we investigated the venous Doppler waveform in two cases of TRAP sequence with a rudimentary heart with cardiac motion in the acardiac twin. Although both cases had veno-venous anastomoses, the venous Doppler waveforms of the umbilical vein differed. A comparison of the characteristics of the cases indicated that the existence of a ductus venosus, or greater heart pulse power, in the acardiac twin might impact the venous Doppler waveform in the pump twin.

Dialysis Treatment is an Independent Risk Factor for Foot Morbidity.

Aim: To determine the prevalence of foot morbidity among patients with ESRD on dialysis. Methods: A prospective, non-experimental, quantitative time series design was employed. Forty-seven participants were recruited in the study. Medical records were reviewed followed by non-invasive foot assessments which included: Neurological, Arterial, Biomechanical, and Dermatological Assessment. Participants were assessed twice during the study. Results: Foot morbidity was found to be high among participants with ESRD on dialysis. 95.74% of participants presented with foot deformities, 76.60% had skin and nail conditions. 15% of participants had a history of ulceration and amputation. Moreover, active ulceration and history of revascularisation were also observed. Findings demonstrated overall poor foot health and footcare behavior within this population with 40.43% of participants having inappropriate footwear. The majority of participants did not check feet regularly, did not attend to podiatry appointments, and were unable to reach their feet for self-care. The Toe Brachial Pressure Index (TBPI), Spectral Doppler Waveform Analysis, and the Quantitative Sensory Testing (QST) were re-measured at each visit. Monophasic continuous doppler waveforms increased while triphasic waveforms decreased during the study period. Protective sensation did not decrease during the study period. The mean TBPI decreased during the study period. The relationship between the TBPI and duration of dialysis was found to be significant. Both DM and dialysis duration were identified as significant predictors of reduction in TBPI. Conclusion: This study demonstrates a high prevalence of foot morbidity among patients with ESRD on dialysis. This study highlighted the importance of expanding practice by introducing a podiatry service within the renal unit to provide foot screening, foot assessments, and foot care education, with the aim to reduce severe foot complications.

VP37.09: Sequential analysis of uterine artery Doppler waveform in women at high‐risk of pre‐eclampsia undergoing low‐dose aspirin prophylaxis

VP37.09: Sequential analysis of uterine artery Doppler waveform in women at high‐risk of pre‐eclampsia undergoing low‐dose aspirin prophylaxis

The Incidence of Peripheral Artery Disease in Patients with Rheumatoid Arthritis

Objectives: The basic aim of this study was to find the expression of PAD in a group of Rheumatoid arthritis participants but with no record of any cardiovascular diseases. Methods: On Ninety subjects with no record of considerable CVD but with RA a prospective observational non-experimental studywas performed. Doppler spectral waveform analysis and Ankle Brachial Pressure Index for vascular judgment was performed. Place and Duration: In the Medicine Department of Aziz Fatima Medical and Dental College Faisalabad for one-year duration from April 2020 to April 2021. Results: In this study total 90 of participants were selected out of which 18 were males and 72 were females. The mean age for this study and time period of RA was 62 ±9.01 and 11.8±11.2 years respectively. It was noticed that seventy five percent of the subjects had triphasic waveforms in the Right foot while sixty percent had in the Left foot when examined the posterior tibial or PT artery. In sixty-eight percent of the total participants triphasic waveforms of the Dorsalis Pedis Arteries were found. Biphasic right was present in thirty percent subjects while biphasic left was present in thirty five percent subjects. Biphasic Dorsalis Pedis was found in forty percent participants of both feet. Only one subject was found with discontinuous monophasic PT of both feet. Conclusions: Results show that ABPI index was discovered normal in majority of patients but waveform analysis was found suboptimal or biphasic in total of one-third of the participants. These results indicatethat to find patients with early PAD the judgment of peripheral arterial perfusion should use both modes. Keywords: Rheumatoid arthritis, ankle brachial pressure value, CVD risks hazards, screening.

Study of Maternal and Fetal Doppler Velocimetry, Histopathology of Placental Bed in Diabetic Pregnancy and Its Correlation to Fetal Outcome

Diabetes mellitus still represents an important medical problem during pregnancy, causing perinatal morbidity and mortality. Despite improved outcome reflected by a steep decline in perinatal mortality over the past few decades, controversy still exists regarding the care of the pregnant woman with both pre-existing and gestational Diabetes Mellitus. Doppler ultrasound is especially valuable during pregnancy because fetal maternal and placental circulations can be studied. The aim of this work was to study the vascular changes in the uteroplacental and fetoplacental circulations, and to correlate these findings with histopathology of the placenta and placental bed, which may occur in association with diabetic pregnancies. The study was carried out on 100 pregnant women of comparable age and parity. They were divided into 2 groups. The control group comprising 20 normal non-diabetic pregnant women and the normotensive diabetic group comprising 80 pregnant diabetic women. All were singleton pregnancies of 34 weeks or more and were delivered by C.S the control and the study cases were subjected to history taking and thorough physical examination. They were also subjected to ultrasonographic examination for fetal biometric parameters and for Doppler examination. Doppler examination included umbilical artery, uterine arteries fetal middle cerebral artery. At the time of C.S the placenta and placental bed biopsy was obtained. After delivery, the Apgar score of the newborn was assessed at 1 and 5 minutes, the body weight was measured, and the fetus was followed up for any complications. Result: There was a positive correlation between the umbilical artery PI and the mean blood glucose levels indicating that poor diabetic control is probably associated with increased umbilical artery PI. However, there was no significant difference between the mean value of the umbilical artery PI in the diabetic and control groups. The uterine arteries Doppler indices showed no significant findings between the diabetic and the control groups. Neither did the uterine arteries Doppler indices show a correlation with the mean blood glucose levels. There was no significant difference between the middle cerebral artery PI in the diabetic and control groups. This observation indicates that there was no redistribution in the fetal circulation in the fetuses of the diabetic group. There was also non correlation between the MCA Doppler indices and the glycemic control. Histopathologic studies of the placental bed showed marked difference between the diabetic group and the control group as regards lack of physiologic changes and arteriosclerotic changes, which emphasizes the effect of diabetes on the placental bed vasculature. Conclusion: Abnormal umbilical artery waveform analysis is one of significant predictors of fetal compromise in diabetic pregnancy, but fetal compromise can occur in association with normal Doppler waveform analysis. In maternal diabetes the classic redistribution seen in fetal hypoxemia due to uteroplacental insufficiency may not occur in diabetic patient even in severely compromised fetuses. In maternal diabetes mellitus, maternal glycemic control has no effect on impedance to flow in the uterine and middle cerebral arteries. No relationship was found between the uterine or umbilical arteries Doppler indices and the placental bed decidual vascular pathology in diabetic pregnancies. There was no correlation between placental findings and the Doppler waveform analysis of the umbilical and the uterine arteries.

Femoral Vein Pulsatility: What Does It Mean?

In this report, the clinical evolution of a 72-year-old patient transferred to the surgical intensive care unit after cardiac surgery is described. The presence of a pulsatile Doppler signal of the common femoral vein was noted after surgery. On postoperative day 5, diuretics in addition to a combination of inhaled epoprostenol and milrinone were associated with normalization of femoral vein pulsatility. The observations seen in peripheral venous flow reinforce the hypothesis that pulsatility of the common femoral vein represents an associated echocardiographic sign of right ventricular dysfunction and may be used to monitor systemic venous congestion. Pulsatility in the venous system may be improved by reducing volume overload and improving right ventricular function.

Doppler waveform analysis during provocative manoeuvres in the assessment for arterial thoracic outlet syndrome results in high false-positive rates; a cross-sectional study.

ObjectivesThere is a high rate of false-positive arterial Thoracic Outlet Syndrome (ATOS) diagnoses due to limited research into the optimal use of ultrasound. To improve future diagnostic efficiency, we aimed to characterise the haemodynamic effects of different provocative positions and estimate the prevalence of compression in the healthy population.DesignIn this cross-sectional, observational study, the effect of varying degrees of arm abduction on discomfort levels and/or changes in subclavian artery Doppler waveform was analysed in the healthy population; the peak systolic velocity (PSV), systolic rise time (SRT), phasicity and extent of turbulence were recorded.SettingDepartment of the Vascular Studies, Royal Free Hospital.Participants19 participants (11 females, 27.4 ± 5.2 years) were recruited for bilateral scans.Main outcome measuresSeven positions were investigated; the primary outcome was an occlusion or monophasic waveform indicating significant compression and this was compared with the secondary outcome; any physiological discomfort.Results28.9% experienced significant arterial compression in at least one position; 120° abduction was the position with the greatest level of abduction that did not result in significant waveform changes or symptoms. The PSV and SRT were difficult to accurately measure and bore no correlation to the level of compression.ConclusionUltrasound testing in isolation would result in a false indication of TOS in almost 30% of our normal population. With further research, the 120° abduction position may have a lower false-positive rate. The PSV and SRT must be interpreted with caution due to their variability even within the healthy population.

Successful management of early onset fetal growth restriction: A case report

FGR (Fetal Growth Restriction) is a condition in which a fetus fails to attend its predetermined biological genetic growth potential. Growth-restricted fetuses are at increased risk of perinatal mortality and morbidity. Growth restricted babies also have poor long term outcomes of cardiovascular, neurological, cognitive or neurological system. The present case of Early FGR where patient presented to us at at 29+6 weeks of gestation with lag in fetal growth of 3 weeks &amp; an Amniotic fluid Index of 3.2 cm and her pregnancy could be successfully prolonged up to 35+2 two weeks of gestation. The protocol for management of the fetus was as per Delphi consensus and ISUOG guidelines, and we could prolong pregnancy to the maximum possible gestation and delivered a low birth weight fetus with good Apgar score and who did not require Neonatal Intensive Care Unit admission. Tools for diagnosis and follow up of FGR fetus are customized growth charts, sequential ultrasound measurements focusing on declining/crossing growth centiles, functional parameters such as Doppler waveform analysis (umbilical artery (UA), fetal middle cerebral artery, and ductus venosus), Biophysical profile scoring, Cardio tocography and serum biomarkers.

Computer assisted Doppler waveform analysis and ultrasound derived turbulence intensity ratios can predict early hyperplasia development in newly created vascular access fistula: Pilot study, methodology and analysis.

ObjectivesFollowing surgical creation of arterio-venous fistulae (AVF), the desired outward remodeling is often accompanied by the development of neointimal hyperplasia (NIH), which can stymie maturation and may lead to thrombosis and access failure. The aim of this study was to investigate the feasibility of using a non-invasive test, to detect and quantify the turbulent flow patterns believed to be associated with NIH development.DesignThis was a prospective, observational study. Ultrasound derived turbulence intensity ratios (USTIR) were calculated from spectral Doppler waveforms, recorded from newly formed AVF, and were compared with haemodynamic and structural changes observed during the initial maturation period.SettingMeasurements were obtained by accredited Clinical Vascular Scientists, at the Royal Free Hospital, London.ParticipantsPatients with newly created AVF were invited to participate in the study. A total of 30 patients were initially recruited with 19 participants completing the 10 week study protocol.Outcome measuresThe primary outcome measure was the development of NIH resulting in a haemodynamically significant lesion.The secondary outcome was successful maturation of the AVF at 10 weeks.ResultsElevated USTIR in the efferent vein 2 weeks post surgery corresponded to the development of NIH formation (P = 0.02). A cut off of 6.39% predicted NIH development with a sensitivity of 87.5% and a specificity of 80%.ConclusionAnalysis of Doppler waveforms can successfully identify deleterious flow patterns and predict inward luminal remodelling in maturing AVF. We propose a longitudinal follow up study to assess the viability of this technique as a surveillance tool.