Doppler Exam Research Articles

Bingo as a Novel Approach to Skill Building in the Initial Months of Surgical Internship: A Pilot Implementation.

We have observed inconsistencies in residents' experiences regarding important procedures and tasks necessary for patient care. We aimed to improve individual motivation to learn and become facile with specific practices earlier in the timeline of the internship years. Intern Bingo was implemented in a single general surgery residency. Two sites, both tertiary care centers with institutional practices, were utilized. Twenty-four procedures/tasks important to clinical practice were identified, including but not limited to Nasogastric Tube placement, IV insertion, incision and drainage, laceration repair, vascular doppler exam, and clinical documentation. Bingo cards were randomly generated. To assess comprehension, interns taught back necessary components to a senior resident or attending to complete each bingo square; including indications, supplies, steps, troubleshooting techniques, and complications. First, the residents were awarded prizes to complete a row and a full card (a cloth scrub cap and portable pulse-oximeter, respectively). A Likert-scale survey assessing satisfaction was administered following the completion of the internship period. The first row was completed in two weeks and the first full card at four weeks. All participants finished the cards within 8 weeks. 54% of the participants returned the survey and 100% reported positive experiences. 50% felt that bingo created a healthy learning environment with improved teaching, and the remaining 50% were neutral. 75% reported that Bingo positively influenced decisions to seek out opportunities. 100% conveyed a desire to repeat Bingo as mentors. Feedback from the attendings was gathered, with positive assessments of the interns' skills and confidence. Bingo is a simple and easily implemented educational tool that works to alleviate variations in experience early in the internship period. It represents a novel and effective way to motivate the interns to learn important procedures and tasks within the first two months of residency. Cards may be effortlessly tailored to a variety of residency programs and rotations.

Diagnostic Accuracy of an Algorithm for Discriminating Presumed Solid and Gaseous Microembolic Signals During Transcranial Doppler Examinations.

The aim of the work described here was to assess the diagnostic accuracy of a new algorithm (SGA-a) for time-domain analysis of transcranial Doppler audio signals to discriminate presumed solid and gaseous microembolic signals and artifacts (SGAs). SGA-a was validated by human experts in an artifact cohort of 20 patients subjected to a 1-h transcranial Doppler exam before cardiac surgery (cohort 1). Emboli were validated in a cohort of 10 patients after aortic valve replacement in a 4-h monitoring period (cohort 2). The SGA misclassification rate was estimated by testing SGA-a on artifact-free test files of solid and gaseous emboli. In cohort 1 (n=24,429), artifacts were classified with an accuracy of 94.5%. In cohort 2 (n=12,328), the accuracy in discriminating solid/gaseous emboli from artifacts was 85.6%. The 95% limits of agreement for, respectively, the numbers of presumed solids and gaseous emboli, artifacts and microembolic signals of undetermined origin were [-10, 10], [-14, 7] and [-9, 16], and the intra-class correction coefficients were 0.99, 0.99 and 0.99, respectively. The rate of misclassification of solid test files was 2%, and the rate of misclassification of gaseous test files was 12%. SGA-a can detect presumed solid and gaseous microembolic signals and differentiate them from artifacts. SGA-a could be of value when both solid and gaseous emboli may jeopardize brain function such as seen during cardiac valve and/or aortic arch replacement procedures.

Sleep Fragmentation and Obstructive Sleep Apnea Are Associated with High Primary Stroke Risk in Children with Sickle Cell Disease

Background Children with sickle cell disease (SCD) are at elevated risk of developing sleep disorders, 1 which may contribute to the sequelae of their disease. One important sequela of SCD exacerbated by sleep disorders is cerebrovascular stroke. Transcranial Doppler (TCD) screening of large intracranial arteries can detect elevated blood velocity and strongly predict stroke in children with SCD. 2 However, the association between stroke risk, as assessed by TCD, and sleep disorders has not been sufficiently investigated. Main Objective To investigate the association between sleep disorders and abnormal TCD examinations in children with SCD. Design/Methods We evaluated associations between sleep disorder severity with TCD examinations in children with SCD. We selected all participants from the Sickle Cell Clinical Research and Intervention Program (SCCRIP), who underwent polysomnography between 2016 - 2020 and had at least one TCD examination. SCCRIP prospectively recruits patients diagnosed with SCD and includes retrospective and longitudinal collection of clinical, neurocognitive, geospatial, psychosocial, and health outcomes data. 3 The severity of sleep apnea was assessed using the apnea/hypopnea index, separated into total and obstructive apnea/hypopnea indices. The number of oxygen desaturation events per hour of sleep as well as the O2 saturation nadir were recorded. Sleep fragmentation was measured by the total arousal index (events per hour of sleep) and sub-categorized into spontaneous and respiratory-related arousal indices. Transcranial Doppler exams were reported as abnormal with timed average mean maximum velocities (TAMMV) of greater than 200 cm/s, high-conditional > 185 cm/s, low-conditional > 170 cm/s, and normal ≤ 170 cm/s. Exact Wilcoxon rank sum test was used to compare sleep outcomes between two groups. The false discovery rate adjusted p-values or q-values were calculated using Benjamini and Hochberg approach to control for multiple comparisons at a level of 0.05. Results Eighty-four patients met inclusion criteria (genotypes SS/SB0 81 (96%), median age 8.3, range 2.2-23.1, 42 male: 42 female). Six patients had abnormal, six high-conditional, 12 low-conditional velocities, while the remainder (60) had normal TCD exams. Patients with abnormal TCD exams exhibited more severe obstructive sleep apnea (mean AHI 25.0 + 9.1 vs. 5.3 + 8.3, p = 0.003), more severe respiratory related arousals (12.7 + 7.9 vs. 3.2 + 4.5, p = 0.008), and higher total arousals (22.9 + 7.7 vs. 12.9 + 5.8, p = 0.01) than those with normal TCD studies at p<0.05.The number of oxygen desaturation events per hour (mean 10.6 + 10.5 vs. 4.5 + 8.0, p = 0.05) was not significantly different among patients with abnormal and normal TCD exams at q<0.05 but the O2 saturation nadir was significantly less in patients with abnormal TCD exams (mean 74.0 + 5.0 vs. 86.8+9.9, p = 0.007) at q<0.05 (Figure 1). Conclusion In pediatric patients with SCD, a link exists between sleep apnea, O2 saturation nadir, sleep fragmentation, and stroke risk. While the findings of this study establish a correlation between sleep disorders and cerebrovascular complications in SCD, further research is still necessary to fully comprehend the exact role of sleep disorders on stroke risk. Nevertheless, this study underscores the importance of addressing sleep apnea and promoting healthy sleep patterns in pediatric patients with SCD to reduce the risk of stroke.

Pharmacokinetic-Guided Hydroxyurea to Reduce Transfusion Requirements in Ugandan Children with Sickle Cell Anemia: Baseline Data from the Alternative Dosing and Prevention of Transfusions (ADAPT) Trial

Background: Children are the primary recipients of blood transfusions in sub-Saharan Africa where the demand for safe blood far exceeds the supply. Without disease-modifying therapy, sickle cell anemia (SCA) causes excess morbidity, mortality, and healthcare resource utilization, specifically requiring a high reliance on blood transfusions. Hydroxyurea is a safe and effective medication for the treatment of SCA that decreases blood transfusion use in this population, which may offset the costs of improving hydroxyurea access. The widespread use of hydroxyurea in Africa is limited in part by challenges determining an individual's optimal dose; pharmacokinetic (PK) dosing of hydroxyurea may streamline the dosing process, maximizing the clinical benefits and minimizing toxicities. We designed the Alternative Dosing And Prevention of Transfusions (ADAPT) trial to analyze the reduction in transfusion use with hydroxyurea and as a pilot evaluation of the feasibility of PK-guided hydroxyurea dosing in Uganda. Methods: ADAPT (NCT05662098) is a prospective, single-center, open-label cohort study at Jinja Regional Referral Hospital in Uganda. Children 1-10 years old with HbSS were eligible to enroll; those already receiving hydroxyurea or scheduled blood transfusions, or with malignancy, HIV, tuberculosis, or other chronic illnesses were excluded, and those who received a transfusion within 30 days were temporarily excluded. All participants completed a 3-month screening period during which they underwent baseline evaluations and hydroxyurea PK testing. For PK testing, a 500 mg hydroxyurea test dose was administered, and serum was collected 30, 60, and 180 minutes after the dose. Hydroxyurea concentrations were determined via chemical derivatization and high-performance liquid chromatography in Uganda. Area-under-time-concentration-curves (AUC) and Bayesian estimation were then used to calculate the optimal hydroxyurea dose based on target medication exposure. Those for whom hydroxyurea PK evaluation was completed successfully with a dose recommendation between 15-35 mg/kg/day started on their PK-guided hydroxyurea dose; otherwise, participants started on the default dose of 20 mg/kg/day. All participants will be treated on hydroxyurea for a minimum of 12 months during which time both treatment groups will follow the same laboratory monitoring and dose adjustment protocol to achieve the maximum tolerated dose. The primary study endpoint is the incidence rate ratio of blood transfusion use during screening versus treatment. Secondary endpoints include characterization of blood transfusions (indications, risk factors, adverse reactions), feasibility of PK testing, and laboratory and clinical adverse events comparing children started on PK-guided versus default dosing. Results: From June 2022 to January 2023, 106 participants were enrolled, exceeding the projected enrollment pace and goal. The average age (mean ± SD) at enrollment was 4.6 ± 2.3 years, and 50% were female. Per family-reported history, most participants had previously received a blood transfusion (78%) with 15% reporting at least 6 lifetime transfusions. Five percent had a prior stroke. A majority also had a history of pain events (86%), malaria (79%), and dactylitis (74%). Only 2% had previously used hydroxyurea. At enrollment, the median weight-for-height z-score was -0.19 (interquartile range -1.03-0.32), and baseline exam demonstrated a palpable spleen in 20%. Abdominal ultrasonography was completed on all participants, and the spleen was identified in 75% of participants with a mean volume of 132 ± 99 mL. Transcranial Doppler exams were completed on 105 participants (99%) during screening with 13% conditional and 6% abnormal results. Baseline labs (mean ± SD) documented hemoglobin = 7.7 ± 1.3 g/dL and HbF = 10.3 ± 7.1 %. Of 106 children enrolled, 1 died from acute chest syndrome in screening and 2 were withdrawn after moving away from the clinic; 103 successfully initiated hydroxyurea treatment. Conclusion: ADAPT has fully completed enrollment and will prospectively evaluate the effectiveness of hydroxyurea treatment on reducing transfusion use in Ugandan children with SCA, a finding with both individual and public health implications. ADAPT will also provide pilot data regarding the feasibility of PK-guided dosing of hydroxyurea to facilitate safe, effective hydroxyurea use in Africa.

Accuracy of IOTA Simple Rules, IOTA ADNEX Model, RMI, and Subjective Assessment for Preoperative Adnexal Mass Evaluation: The Experience of a Tertiary Care Referral Hospital

Objectives: The aim of this study was to evaluate the accuracy of IOTA Simple Rules (SR), IOTA ADNEX model, Risk of Malignancy Index (RMI), and subjective assessment (SA) which is used for adnexal mass assessment in our institution. Design: This is a prospective observational study. Participants/Materials, Setting, Methods: We included patients with at least one adnexal mass who needed elective surgical evaluation based on clinical and laboratory findings. Patients admitted to Clinic for Gynecology and Obstetrics, University Clinical Center of Serbia, were recruited for the study between January 2019 and June 2021. Level II ultrasonographers performed a gray scale and Doppler exam for each patient. Preoperative classification of adnexal masses (benign or malignant) was performed by SA, the International Ovarian Analysis Group (IOTA) SR, IOTA ADNEX model, and Risk of Malignancy Index (RMI). Postoperatively obtained histological findings were used as a reference. Results: During the study period, we enrolled 179 premenopausal and 217 postmenopausal patients, representing 396 patients in our sample. Prevalence of malignant disease in pre- and postmenopausal groups was 16.2% (29/179) and 41% (89/217), respectively. Malignant disease was diagnosed in 29.8% (118/396) of patients. SA achieved the highest discrimination accuracy between benign and malignant tumors (area under the curve [AUC] of 0.928, 95% CI [0.898–0.952]). For SA, the overall diagnostic accuracy, sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR−) were 91.4%, 88.1%, 92.8%, 12.25, and 0.13. The AUC for Simple Rules with subjective assessment in inconclusive cases (SR + SA) was 0.912 (95% CI [0.880–0.938]). Regarding SR + SA, diagnostic accuracy, sensitivity, specificity, LR+, and LR− were 92.4%, 88.1%, 94.2%, 15.31, and 0.13. The ADNEX model had the AUC of 0.914 (95% CI [0.882–0.940]). Binary classification using the ADNEX model at a cut-off value of 10% for malignancy had the sensitivity, specificity, LR+ and LR− of 92.4%, 73.0%, 3.42, and 0.10. This resulted in the lowest overall accuracy of 78.8%. The AUC for RMI was 0.854 (95% CI [0.815–0.887]), with overall accuracy, sensitivity, specificity, LR+ and LR− of 82.3%, 73.7%, 86.0%, 5.26, and 0.31. There was no difference in the AUCs of the SA and IOTA models for the whole group, premenopausal, and postmenopausal groups. RMI performed worse compared to SA and the IOTA models. The ADNEX model achieved the highest accuracy at the cut-off value of 35%. Limitations: The data generalizability is limited by a single institution-dependent sampling. Conclusions: The IOTA SR and ADNEX model were reliable and comparable with the SA and performed better than the RMI. The IOTA SR model offers the potential for immediate and reliable diagnosis, even in the hands of less experienced ultrasonographers. Both IOTA models studied can be a valuable adjunct to a clinician’s decision-making process.

Optimizing the Frequency of Transcranial Doppler (TCD) Exams in Children with Sickle Cell Anemia

Background Transcranial Doppler (TCD) screening of the large intracranial arteries can detect elevated blood velocity and is a strong predictor of stroke risk in children with sickle cell anemia (SCA, HbSS and HbSβ0-thalassemia). Initiation of chronic blood transfusion for patients with confirmed abnormal TCD velocities (time-averaged mean velocity, TAMV≥200 cm/sec) is shown to effectively reduce primary stroke. Current guidelines recommend annual TCD screening for children with SCA ages 2-16 years. Screening intervals were developed following evidence from the STOP studies1 (Figure 1). The estimated prevalence of normal TCD velocities is 83%2 and these children will have received 15 TCD exams from ages 2 to 16 if all results remain within normal range. The cumulative incidence of conversion from normal to conditional TCD velocities is dependent on age, whereby the risk is four times lower in children >10 years, compared to those <10 years of age3. Although TCD screening is non-invasive and safe, it consumes time and requires specialized equipment and trained examiners. Identifying sub-populations for whom TCD screening frequency could be safely reduced could lessen time burden on patients and caregivers and could be cost saving. Main objective To estimate the risk of TAMV conversion from normal to conditional or abnormal categories among children with SCA relative to age. Design/Method We included all participants with SCA from the Sickle Cell Clinical Research and Intervention Program, a longitudinal lifetime cohort of patients with SCD with at least one TCD measurement available both before and after age 10 years. We classified participants into two groups based on TCD screening results before 10 years of age; one group with all normal TCDs, and the other group with at least one non-normal TCD. We then compared the time to first non-normal study after ten years of age between the two groups using the log rank test. Time to first conversion was defined as time from age 10, to time of conversion if conversion occurred, or time to last follow up if no conversion occurred. We correlated the number of TCD exams before age 10 with time to first conversion using the Cox proportional regression model. Exposure to chronic transfusion or hydroxyurea before age 10 and age at first TCD measurement were covariates and were correlated with the time to first conversion. Results Of the 614 patients with TCD screening, 297 had SCA and at least 1 screening before and after age 10 (Table 1). Of these, 174 patients had only normal TCD screening before age 10 and the remaining 123 patients had at least 1 non-normal TCD screening before age 10. During the time they were followed,no patients with only normal TCD screenings before age 10, regardless of exposure to hydroxyurea or transfusions, had a conditional or abnormal TCD exam. Conversely, 41.5% of patients with at least one non-normal TCD before age 10 had a conditional or abnormal TCD screening after age 10. Conclusion In a large retrospective cohort study analysis of children with SCA, patients with TCD exams consistently within the normal range under age 10 years were not at risk of conversion to conditional or abnormal TAMV. These results suggest that children with SCA with all normal TCD velocities before age 10 years may not require additional TCD screening exams after age 10. These results translate to 6 fewer TCD exams per each child with SCA over age 10 with all prior normal TCD exams, potentially conserving resources and reducing burden on patients, families, and the health system. De-implementation studies to reduce the use of TCD screening exams in low-risk cases are needed

Late-onset fetal growth restriction management: a national survey.

Fetal growth restriction (FGR) is an obstetric condition that increases the risk of adverse neonatal outcomes. FGR antenatal care aims to decrease fetal morbidity and mortality through optimal fetal monitoring. However, no univocal strategies for late-onset FGR outpatient management are available, and this survey investigated gynaecologists' attitudes concerning outpatient frequency tests. We mailed a survey to 429 Italian gynaecologists. The primary purpose was the ambulatory care of late-onset FGR without doppler alterations evaluation. The queries estimated the self-reported medical practice regarding cardiotocography (CTG) and obstetric ultrasound exams before hospitalization. Statistical analysis was performed with Stata 14.1 (Stata corp., College Station, TX, USA) for symmetrically distributed continuous variables, and the mean differences were analyzed using the t-test. Where appropriate, the proportions between the groups were evaluated using Fisher's exact or χ2 test. All P value <0.05 were considered statistically significant. 128 responses (29.8%) from the 429 SCCAL members were available for the survey. 39.9% of respondents had a late FGR standardized protocol. Regarding non-severe FGR with normal fetal doppler, 70.8% suggested a fetal doppler study after one week (92/128), 13.8% (18/128) and 6.9% (9/128) proposed the exam, respectively, two and three times for a week. 0.8% (1/128) of respondents had a daily doppler exam, 7.7% (10/128) did not answer, and 3.1% (4/128) repeated the ultrasound exam to time for a week. The antenatal CTG was offered: 70.8% (92/128) of gynaecologists recommended one weekly CTG, whereas 13.8% (18/128) suggested two. 6.9% (9/128) recommended three weekly tests and 0.8% a daily test. 7.7% (10/128) of gynaecologists did not respond. At least, we investigated the gynaecologist's recommendations for outpatient EFW evaluation: 59.4% (76/128) repeated EFW after two weeks, 31.3% (40/128) after one week. 3.9% (4/128) and 3.1 (4/128) recommended EFW after three weeks and twice a week. Gynaecologists recommend unnecessary cardiotocography and ultrasound Doppler exams for non-severe late-onset FGR with normal doppler. However, additional studies and comprehensive surveys are needed to support a standardized protocol and assess the feto-maternal outcomes impact.

S374 Endoscopic Coiling of Mesenteric Varices Causing Stomal Bleeding Caused by Extensive Portal Vein and Superior Mesenteric Thrombus

Introduction: Ectopic varices are collateral vessels located outside the gastro-esophageal area. Small bowel varices, while an uncommon result of portal hypertension can be a life-threatening cause of gastrointestinal bleeding. We present a case of refractory stomal bleeding secondary to mesenteric varices, treated with endoscopic ultrasound (EUS) guided coiling. Case Description/Methods: A 54-year-old male presented with history of ulcerative colitis status post proctocolectomy and ileostomy, primary sclerosing cholangitis (PSC), and auto-immune hepatitis (AIH) overlap syndrome treated with a deceased donor liver transplant in 2019. This was further complicated by portal hypertension secondary to portal vein and superior mesenteric vein thrombus. The patient presented with refractory stomal bleeding at this ileostomy site requiring multiple blood transfusions. On CT imaging, prominent mesenteric varices extending to the area of the stoma were noted. An interventional radiology (IR) approach from the portal system was not feasible given thrombosis in the portal vein and superior mesenteric vein. Percutaneous IR approach was also felt to be suboptimal given the depth of the peri-stomal varices. After a multidisciplinary discussion, the patient underwent ileoscopy with EUS guided coiling of the terminal/culprit branches of the mesenteric varices. The linear echoendoscope was introduced through the ileostomy and advanced approximately 5-10cm. Multiple tubal anechoic structures consistent with varices were noted with flow seen on doppler examination. This was confirmed on pulse wave doppler. A large feeding variceal vein towards the patient’s left side was punctured with a 22G needle. Saline was injected and it was visualized on EUS to confirm location. Next, embolization coils (8mm x 2, 10mm x1) were inserted for varix eradication. Reduced flow downstream of the coiling site was confirmed on doppler exam after embolization. Brief fluoroscopic images showed appropriate placement of coils in the patients right lower quadrant, without any migration. There was no significant flow toward the lumen on EUS after coiling. Since this procedure, the patient’s stomal bleeding resolved. (Figure) Discussion: Small bowel varices in the setting of significant portal hypertension are a rare but clinically significant cause of gastrointestinal bleeding. EUS-guided interventions such as coil embolization can be an effective treatment modality, especially in patients who are poor interventional radiology candidates. Watch the video at https://tinyurl.com/ACGAbstractS374Figure 1.: (1a) Prominent mesenteric varices extending into the ostomy (1b) EUS-guided coil embolization (1c) Status post successful endoscopic coil embolization

S2818 Endoscopic Removal of a Symptomatic Benign Esophageal Sub-Mucosal Lesion

Introduction: The esophagus is a rare site for benign mucous duct cyst(mucocele). Mucoceles commonly occur from an obstructing salivary gland duct or rupture of the salivary gland. Therefore, mucoceles are most often found in the oral cavity. Symptomatic esophageal polyps or cysts have traditionally required surgical intervention. Endoscopic resection has become an option over the last few years and includes endoscopic mucosal resection or submucosal dissection. We present a case of an esophageal submucosal polypoid lesion that was removed endoscopically and revealed a rare and interesting pathology Case Description/Methods: A 70 year old female was referred for evaluation of reflux symptoms. During her initial outpatient visit she described worsening reflux symptoms and dysphagia. initially having dysphagia just to liquids but now progressing to solids. A trial of pantoprazole significantly improved her reflux symptoms but her esophageal dysphagia persisted. An upper endoscopy revealed a polypoid lesion at least 2.5 cm in length in the upper third of the esophagus (Figure a). A 2.5 cm heterogenous polypoid lesion without vascularity was seen on endoscopic ultrasound and doppler exam. Given lack of vascularity, the decision was made to attempt endoscopic resection. An endoloop was used to place at the base of the lesion, followed by resection(Figure b) Endoscopic appearance was most consistent with a fibrous polyp. Histologic study demonstrated the wall consisted of two muscle layers consistent with benign mucous cyst (Figure c). On follow up patients’ symptoms had resolved Discussion: A symptomatic esophageal polyp identified on an endoscopy carries an extensive differential diagnosis ranging from benign to malignant. Esophageal mucoceles are thought to occur due to recanalization of the upper digestive tract with subsequent coalescence of vacuoles. Histologically, benign mucous cysts are lined with two muscle layers. Prior cases have reported mucoceles emerging in the esophageal remnant directly following bypass surgery or secondary to tracheoesophageal fistula. We report a unique case of spontaneous emergence of mucocele without an obvious prior etiology or pre-disposing surgical intervention. Rarely, an esophageal cyst causes symptoms of dysphagia or regurgitation requiring removal. Endoscopic resection has gained popularity in recent years, due to the low rates of morbidity and mortality. Additional reports of esophageal mucoceles will help in understanding this rare condition better.Figure 1.: a: Endoscopic appearance of an esophageal submucosal lesion; b: nodule post-resection; c: Histologic study demonstrated the wall consisted of two muscle layers consistent with benign mucous cyst.

Early detection of ischemic brain injuries by diffusion-weighted imaging after radiofrequency ablation for fetal reduction in monochorionic pregnancies.

This study aimedto investigate the additional advantages of magnetic resonance imaging (MRI), particularly diffusion-weighted imaging (DWI) over fetal ultrasound in the detection of acute ischemic cerebral injuries in complicated monochorionic (MC) pregnancies that underwent selective reduction by radiofrequency ablation (RFA). This prospective cohort study was conducted on 40 women with complicated MC pregnancies who were treated by RFA. Fetal brain imaging by DWI and conventional MRI was performed either in the early (within 10 days after RFA) or late phase (after 3-6 weeks) in the surviving fetuses to detect both acute and chronic ischemic injuries. The presence of anemia after RFA was also evaluated by Doppler ultrasound. Overall, 13 of the total 43 fetuses (30.23%) demonstrated MRI abnormalities with normal brain ultrasound results including germinal matrix hemorrhage (GMH), extensive cerebral ischemia, and mild ventriculomegaly. Although seven fetuses with GMH eventually survived, fetuses that demonstrated ischemic lesions and ventriculomegaly on MRI died in the uterus. The absence of abnormal cerebral lesions or anemia on ultrasound and Doppler exams does not necessarily rule out fetal brain ischemia. Performing early MRI, particularly DWI seems to be a reasonable option for detection of early intracranial ischemic changes and better management of complicated multiple pregnancies which were treated by RFA.

Lidocaine Incorporated Alprostadil-phentolamine Urethral Gel for Erectile Dysfunction: Patient Tolerability and Satisfaction

ABSTRACT Introduction Localized therapy remains an important tool in the armamentarium against ED in patients who decline surgical intervention. Options include intracavernosal injections (ICI) and intraurethral (IU) therapies. For patients averse to injections, IU can be an option. Discomfort is a common side effect of IU therapies. Objective Herein, we assess the use, tolerability and satisfaction of a lidocaine incorporated IU gel treatment including phentolamine and alprostadil. Methods In this single-center study, 75 patients were telephonically surveyed following the prescription of IU lidocaine-alprostadil-phentolamine gel for ED. Prior to IU therapy, all patients had ICI incorporated penile Doppler exams as part of their routine ED workup. Each survey consisted of 5 questions from the validated Sexual Health Inventory for Men (SHIM) questionnaire and 4 questions regarding satisfaction with IU therapy. Patients were excluded if they did not fill their IU prescription, did not answer after 3 attempted calls, declined participation, or were non-English speaking. Clinico-demographic factors were analyzed using chi-square, t-tests, and logistic regression to determine associations of treatment satisfaction. Results Out of 75 patients, 39 had treatment data available for analysis. Median age of the cohort was 61 years (IQR 56-66). Hypertension and hyperlipidemia were the most common comorbidities within the group at 21 (53.8%) patients and 13 (33.3%) patients, respectively. Surveys were conducted a median 128 days after initial prescription. In total, 15 (38.4%) patients were satisfied with IU treatment. Thirty-seven (94.9%) patients did not report pain with IU gel usage. Prior success with &amp;lt;10 units of ICI alprostadil-papaverine-phentolamine (during penile Doppler or as a previous therapy) was associated with increased treatment satisfaction (p=0.039). Post-treatment SHIM scores were also associated with increased treatment satisfaction (p=0.047). Factors such as age, time since initial insult, hypertension, or hyperlipidemia were not found to influence treatment satisfaction. Conclusions IU therapy is an acceptable alternative in patients interested in localized ED therapy who are averse to ICI. Patients who responded to &amp;lt;10 units of ICI was associated with IU treatment satisfaction. IU therapy has a success rate of ∼33%, with the most common adverse event being discomfort. In this study, lidocaine incorporated IU gel offered similar efficacy (38.4%) and is well-tolerated with 94.9% reporting no discomfort. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientic, Coloplast, Neotract

Analysis and Classification of Postcatheterization Femoral Arteriovenous Fistulas Based on Color Doppler Examinations.

To analyze and classify arterial supply and venous drainage of postcatheterization femoral arteriovenous fistulas (AVFs). A review of extremity Doppler reports identified 77 femoral AVFs in 75 patients. Doppler exams were reviewed retrospectively. Fistulas were classified as above or below the common femoral artery bifurcation and subclassified based on the location of arterial inflow and venous outflow. Arterial inflow originated above the femoral bifurcation in 32 cases. The communication was between the common femoral artery and the superficial circumflex iliac vein in 25 of 32 cases and between a branch of the common femoral or external iliac artery and the common femoral or external iliac vein in 4 of 32 cases. In 3 of 32 cases, AVFs arose from the common femoral artery, but the venous outflow was not determined. Arterial inflow originated from the superficial femoral artery in 23 cases. Venous outflow originated from the common femoral vein in 10 of 23 cases, the femoral vein in 7 of 23 cases, and the lateral circumflex femoral vein in 6 of 23 cases. Arterial inflow originated from the deep femoral artery in 12 cases. Venous outflow originated from the common femoral vein in 6 of 12 cases and from the lateral circumflex femoral vein 6 of 12 cases. In 8 cases, the AVF originated below the bifurcation, but the arterial inflow was not classified. In 2 cases, it was impossible to determine if the AVF originated above or below the bifurcation. Iatrogenic femoral AVFs arise above the femoral bifurcation more often than previously recognized. Classification based on the arterial inflow and venous outflow provides a straightforward means of describing these fistulas.

Clinical Effectiveness of Peripheral Nerve Blocks for Diagnosis of Migraine Trigger Points

BACKGROUND: With a 13% global prevalence, migraine headaches (MH) are the most commonly diagnosed neurologic disorder and are a top 5 cause of visits to the emergency room. Surgical techniques—such as decompression and/or ablation of neurovasculature—have shown to provide relief in patients suffering from MH. Popular diagnostic modalities to identify trigger loci include handheld doppler exams and botulinum toxin injection. This article aims to establish the positive predictive value (PPV) of peripheral nerve blocks for identifying therapeutic surgical targets for MH surgery. METHODS: Charts of 36 patients were retrospectively analyzed. These patients underwent peripheral nerve blocks using 1% lidocaine with epinephrine and subsequent surgery on identified MH trigger points. Patients were grouped into successful and unsuccessful blocks and further categorized into successful and unsuccessful surgery subgroups. Group analysis was done using paired t tests and PPV calculations were done on subgroups. RESULTS: Mean postsurgical follow-up was 11.5 months. Prior to surgery, Migraine headache index of patients was 168.16 versus 43.69 after surgery (P < 0.001). Each of the components of Migraine headache index also significantly decreased: frequency (24.54 MH/mo versus 8.53; P < 0.001), intensity (7.33 versus 4.75; P < 0.001), and duration (0.8 days versus 0.39; P < 0.001). The PPV of diagnostic peripheral nerve blocks in identifying a MH trigger point responsive to surgical intervention was calculated to be 0.89 (95% CI, 1, 0.74). CONCLUSION: Peripheral nerve blocks serve as a clinical tool in mapping migraine trigger points for surgical intervention while offering more flexibility in their administration and recording as compared to established diagnostic methods.

Atypical manifestations of recent syphilis: study of 19 cases

BackgroundSyphilis is one of the most common diseases that start with genital ulcers. Aside from the initial, classic ulcerative lesion of syphilis, called hard chancre, atypical presentations are common, with erosions, erythema, edema, balanitis, and other dermatological manifestations. Associated with initial genital lesions, the presence of inguinal adenopathies is frequent, and the presence of hardened and painless lymphangitis on the dorsum of the penis is rare. ObjectivesTo describe atypical penile manifestations in patients with early syphilis. MethodsThe present study reports patients who developed cord-like lesions on the penis. ResultsThe study included 25 patients with cord-like lesions on the penis; in 19 of those, the diagnosis of syphilis was confirmed. Study limitationsSmall number of patients included. ConclusionsIn view of the findings of the present investigation, it is important to emphasize that all patients who present with cord-like lesions on the penis must undergo a rapid test for syphilis, VDRL, serologies for HIV viral hepatitis B and C and, whenever possible, histopathological and Doppler exams.

Effect of Distal Cephalic Vein Ligation on Primary Patency Rates and Proximal Flow Rates in Distal Radiocephalic Fistula.

Introduction:The Brescia-Cimino radiocephalic fistula, originally devised as a side-to-side anastomosis, is simple to perform and provides a smooth vein–artery interface but requires greater mobilization for vein–artery approximation than does the end-to-side approach. Distal cephalic vein ligation is performed to prevent venous hypertension. The study aims to assess primary patency at one month following distal side-to-side radiocephalic fistula creation with and without distal cephalic vein ligation, to assess the effect of distal cephalic vein ligation on flow rates at one month, and to document the occurrence of venous hypertension over one year follow up.Method:A total of 100 patients requiring vascular access for hemodialysis were assigned to side-to-side anastomosis with and without distal cephalic vein ligation. Follow up Doppler exam was performed at one month for assessment of patency and flow rates and after one year clinical exam to document venous hypertension and the need for revision surgery. The quantitative and qualitative variables were evaluated using student t test and chi square test, respectively.Results:The patency rates of distal ligation and no ligation groups were 86.4% and 85.4%, respectively. The proximal flow rates of distal ligation and no ligation groups were 1192+/−812 ml/min and 1217+/−796 ml/min, respectively. The difference was not statistically significant (P > 0.05). Only two cases (5%) with no ligation required revision ligation within one year of surgery.Conclusion:Distal cephalic vein ligation does not increase the proximal cephalic flow rates and primary patency rates after one month. However, venous hypertension was associated in 5% of nonligated cases at one year follow up.

Ultrasonographic evaluation of umbilical structures in Holstein calves: A comparison between healthy calves and calves affected by umbilical disorders

The aim of this study was to evaluate, during the first 4 wk of life, the involution of umbilical structures in clinically healthy calves and in calves affected by umbilical disorders, in both B-mode and color Doppler ultrasonography. The present study was carried out on 63 Holstein Friesian calves, divided into 3 different groups: group H (clinically healthy, n = 17), group A, (affected by omphaloarteritis, n = 24), and group V (affected by omphalophlebitis, n = 22). B-mode ultrasonography was performed at weekly intervals, using a portable device (LOGIQ Book XP, GE Healthcare, Little Chalfont, UK) and a linear multifrequency 7 to 10 MHz probe. In addition to the ultrasound examinations, the umbilicus of the calves was also evaluated using a color Doppler. The extra-abdominal as well as the intra-abdominal hemodynamics within the umbilical structures were evaluated using 3 different ranges of speed-flow detections (23, 14, and 7 cm/s). In healthy calves, as the age increased, the umbilical structures decreased in size and their ultrasonographic identification became more difficult. Conversely, in affected calves the umbilical structures did not show the same progressive reduction of external diameters and areas, but had an irregular trend of regression. Also the color Doppler ultrasonography showed a significant difference in frequency and percentage of speed-flow in the early days of examination between the 3 groups, with the most reliable results detected from the umbilical arteries. In our experimental study, omphaloarteritis could be detected at the d 1 color Doppler exam, with a 100% specificity and a 100% positive predictive value.

Ultrasonographic evaluation of feto-placental tissues at different intrauterine locations in rabbit

The main purpose of examining multiparous species with real-time ultrasonography is to determine the gestational age and make various fetal measurements for early diagnosis of growth anomalies and sibling mismatches. This study investigated changes in fetometric measurements, obstetric Doppler indices and placental image analysis results based on gestational age and fetal location in fetuses located cranially and caudally between 16 and 24 days gestation in 22 healthy pregnant New Zealand rabbits. The first study group consisted of fetuses positioned at the cranial end (n = 22) while the second group consisted of fetuses positioned at the caudal end (n = 22) in each pregnancy. Fetal biparietal head diameter (BPD) and trunk diameter (TD) were measured, and mean grayness values (MGV) were determined from placental image analysis of each fetus. Using Doppler USG, the pulsatile (PI) and resistance (RI) indices of the uterine artery (UtA) and umbilical artery (UmA) were recorded. By the end of the study, BPD and TD values for cranial and caudal fetuses had significantly increased with gestational age (P < 0.001). The MGV values of caudal fetuses were significantly higher (except for the 16th day) (P < 0.05). The UtA PI value of the caudal fetuses was significantly higher (except for the 18th day) (P < 0.01). The UtA RI values of caudal fetuses were significantly higher than cranial ones on the 16 and 24th days (P < 0.05). The PI of the UmA increased until the 20th day before decreasing significantly in both study groups (P < 0.001). The UmA RI value decreased according to the gestational age in both groups (P < 0.001). It was significantly higher in the caudal fetuses on the 20th day (P < 0.05). The somatic rate of all fetuses peaked at the end of the second trimester, although caudal fetuses had higher fetometric values, and this location difference also affected placental echotexture. In both vessels of caudal fetuses, pulsatility and resistance values were higher. The 20th day of pregnancy was a threshold for the Doppler exam results. In conclusion, growth and metabolic status of fetuses located in different uterine locations in healthy pregnant New Zealand rabbits vary. Based on the these growth curves and hemodynamic data, more comprehensive studies of intrauterine life may be possible.

Carotid Artery Blood Flow and Its Association with Stroke during Left Ventricular Assist Device Support

Purpose Left ventricular assist device (LVAD) surgery is a life-prolonging therapy for advanced heart failure (HF). Despite many improvements over the years, LVADs continue to be associated with a high incidence of stroke and other vascular complications such as gastrointestinal bleeding (GIB). At present, the pathogenesis of these complications during LVAD support remains unclear. Abnormal structure and hemodynamics in large arteries are a potential contributor. We hypothesized that structural abnormalities and flow alterations will be significantly associated with stroke and a composite outcome of stroke, GIB, and death in HF patients before and during LVAD support. Methods We conducted a retrospective analysis of 141 carotid duplex studies in adult patients who received the HeartMate II LVAD. Clinical Doppler exams were evaluated before and after LVAD implantation. Parameters evaluated included peak-systolic velocity (PSV), end-diastolic velocity (EDV), mean velocity (MV), pulsatility index (PI), ICA/CCA PSV ratio, plaque burden, and ICA stenosis. In addition, we noted demographics, outcomes, and LVAD speed parameters. Results Compared with HF patients, LVAD patients had decreased PSV (CCA: 80 vs. 50 cm/s, ICA: 72 vs. 56 cm/s; both P Conclusion We conclude that structural arterial disease in HF patients, namely carotid artery stenosis and plaque as evidenced by Doppler evaluation, was associated with stroke, GIB, and death during LVAD support while arterial flow parameters were not. Flow parameters during LVAD support were likewise unrelated to adverse events. Our findings support routine carotid duplex evaluation for clinical outcome prediction and encourage further study of the unique vascular physiology resulting from LVAD support.

Movement artifacts in pediatric cutaneous ultrasonography

Cutaneous ultrasonography can be challenging in children. We aim to identify the most complicated cases and the best timing for assessment. We retrospectively reviewed sonographic exams in pediatric patients from our cutaneous ultrasonography clinic over a two-year period. Movement artifacts were classified according to their consequences and their frequency was studied in relation to the age of the patient, location of the lesion, and underlying pathology. The overall frequency of exams affected by movement artifacts was 16.76% (91/543) and all belonged to children younger than 4 years of age. The frequency of impaired sonographies was particularly low in patients aged 0 to 4 months (12.77%; 6/47) and particularly high in children aged from 4 to 12 months (56.60%; 60/106). Regarding location, exams were more frequently disadvantaged when assessing the head and neck area (44.53%; 61/137). In relation to pathology, developmental anomalies showed a significantly higher frequency of exams damaged by movement artifacts (41.82%; 23/55). Cutaneous ultrasonography without sedation can be particularly difficult in children aged between 4 and 12 months, especially when lesions are located on the head and neck and a Doppler exam is required. When assessing congenital lesions, the first four months of life are ideal for a first examination.

The role of cervical color Doppler ultrasound in the diagnosis of brain death

Brain death (BD) is defined as the irreversible destruction of all brain functions. It is usually diagnosed through a clinical examination, but in certain circumstances, ancillary examinations (such as digital subtraction angiography (DSA), transcranial color Doppler (TCD), computed tomography angiography (CTA), magnetic resonance angiography (MRA), or radionuclide scanning) are required as confirmatory tests. In many countries, cervical color Doppler sonography (CCD) is not recognized as a valid test. The aim of our study is to assess its accuracy as a non-invasive, inexpensive, and easily available examination to determine cerebral circulatory arrest (CCA). We performed a retrospective study in which 123 patients with clinical diagnosis of BD underwent bedside cervical color Doppler as an additional examination for CCA assessment. We compared these cervical color Doppler findings with the results of validated ancillary tests such as CTA, TCD, and DSA. Cervical color Doppler exams showed a sensitivity of 78% (96/123 patients) in detecting CCA compared to standard ancillary tests. Twenty-seven patients showed a persistent diastolic flow in one or two of the four arterial vessels examined and thus considered as false negatives. Our results show that cervical color Doppler may become a reliable and safe technique in detecting CCA, which can shorten the time for declaring brain death. In particular, in patients lacking good bone windows at transcranial color Doppler, cervical color Doppler of the cervical internal carotids and vertebral arteries could be recommended to increase the sensitivity of transcranial color Doppler, or as an alternative bedside examination.