Valsalva Research Articles

Cauda equina movements during the Valsalva maneuver in patients with lumbar spinal stenosis: introducing a novel method for redundant nerve evaluations.

To investigate whether inchworm-like cauda equina movements can be observed in patients with lumbar spinal stenosis using a novel Valsalva maneuver cine MRI (cMRI) protocol. Fifteen lumbar spinal stenosis patients (11 males; mean age, 73.9years) underwent lumbar static MRI (sMRI) and sagittal 60-s cMRI. The cMRI protocol, called the Kinematic Assessment of Redundant Nerves (KAoRN), included three resting and Valsalva maneuver sets. Two radiologists independently evaluated cauda equina movement and lumbar spinal stenosis severity from L1/2 to L5/S1 using an MRI lumbar spinal stenosis score. Scores from both analysts were averaged; the most severe averaged score from all levels was extracted and defined as the worst score. Moreover, the level at which severe stenosis (averaged score ≥ 3.5) was observed was counted. KAoRN-positive cauda equina movement was observed in 11 participants (73.3%). KAoRN-negative participants tended to have non-significantly higher worst lumbar spinal stenosis scores (4.0, interquartile range 3.9-4.0) than those of KAoRN-positive participants (3.5, interquartile range 3.0-4.0) (p = 0.310, χ2 test). KAoRN-negative participants tended to have more severe stenosis than that of KAoRN-positive participants, though the difference was not significant (p = 0.182, Wilcoxon rank sum test). KAoRN-positive cauda equina movement is frequently observed in participants with lumbar spinal stenosis; however, it is not observed in all such cases. Further exploration of the differences in the presence or absence of KAoRN-positive findings may provide new insights into the diagnosis of clinically relevant LSS requiring surgical intervention. The UMIN clinical trial number: UMIN000052276.

Valsalva-induced orbital and subcutaneous periorbital emphysema secondary to lamina papyracea dehiscence: case report

Introduction: Pneumo-orbit and periorbital subcutaneous emphysema secondary to defects in the sinus wall have been well described in the context of traumatic or surgical sequelae. However, these rarely occur atraumatically in the setting of an idiopathic or congenital sinus wall dehiscence, with a risk for orbital compartment syndrome and irreversible vision loss. We describe a case of idiopathic lamina papyracea dehiscence with resultant pneumo-orbit and elevated intraocular pressure. Case Presentation: A 28-year-old man experienced a sudden onset of unilateral orbital and subcutaneous periorbital emphysema following Valsalva maneuver. He had unilateral subcutaneous emphysema, crepitus, violaceous discolouration of the lids, and chemosis of the palpebral conjunctiva. Visual acuity was intact and intraocular pressure was mildly elevated. Imaging showed an idiopathic lamina papyracea dehiscence. The patient was advised of sinus precautions with uneventful spontaneous resolution and no visual sequelae. Conclusion: Lamina papyracea dehiscence predisposes to spontaneous Valsalva-induced orbital or periorbital emphysema with a risk of elevated intraocular pressure, optic neuropathy, and vision loss; prompt recognition and early management can prevent vision-threatening sequelae.

Functional disorders of the lower urinary tract following urogynecologic and abdominal surgery

Bladder dysfunction is divided into storage and emptying disorders, which can also be the result of surgical interventions in the small pelvis, either individually or in combination. Neuroirritants from alloplastic implants are often associated with urge complaints and pelvic pain. Removal of the irritant agent carries the risk of incalculable collateral damage and recurrence of the symptoms that initially led to surgery. Conservative measures, on the other hand, are often lengthy, multimodal, and yet frustrating. Iatrogenic denervation of the lower urinary tract-mainly due to damage to the pelvic plexus-can be asymptomatic for years and remain undetected, because detrusor hypo- or acontractility can be compensated for by using alternative emptying mechanisms (Valsalva maneuver, pressureless micturition via pelvic floor relaxation). Neuromodulative therapeutic approaches require residual contractility of the detrusor, in the case of complete acontractility, only intermittent self-catheterization and suprapubic urinary diversion remain as therapeutic options. Iatrogenic urogenital fistulas occur most frequently after hysterectomies in benign indications, and the risk of afistula following vaginal hysterectomy is tenfold with laparoscopic approaches. Due to the heterogeneity of fistulas, acorrespondingly broad range of therapies must also be provided and, in addition to conservative permanent catheterization, also include vaginal or transabdominal fistula closure strategies.

The Use of Transperineal Ultrasonography to Compare Relevant Factors for Postpartum Urinary Incontinence Related to Different Modes of Delivery.

Studies concerning the similarities and differences in relevant factors for PPUI inpuerpera with delivery modes are scarce. This study aimed to investigate relevant factors for PPUI among primiparas grouped by different delivery modes using transperineal ultrasonography. This is aretrospective cohortstudy. Seven hundred thirty-eight primiparas were included and their clinical and ultrasonographic data were collected. First, they were divided into the UI group (n = 233) and non-UI group (n = 505). Then all participants were redivided into the vaginal delivery without episiotomy group (n = 271), the vaginal delivery with episiotomy group (n = 158), and the cesarean section group (n = 309). Independent relevant factors of PPUI were analyzed with the delivery mode as one of the variables and as a grouping factor, respectively. BMI, delivery modes, vertical distances between the location of bladder neck and the reference line of the inferior symphyseal margin at rest (BSDr), and [bladder neck descent (BND)]/BSDr were independently associated with PPUI in the overall study population. Among the participants grouped by delivery modes, the maternal BMI, BSDr, and retrovesical angle during Valsalva maneuver (RVAv) were independently associated with PPUI in the vaginal delivery without episiotomy group. BND/BSDr was the independent relevant factor of PPUI in the cesarean section group. In the vaginal delivery with episiotomy group, no factors were independently associated with PPUI. The independent relevant factors for PPUI in primiparas varied with delivery modes. Sonographic measurements were independently associated with PPUI related to different delivery modes, acting as differential markers to identify PPUI.

Balloon eustachian tuboplasty in chronic suppurative otitis media and dilatory eustachian tube dysfunction: a randomized controlled trial.

Balloon eustachian tuboplasty (BET) is an emerging treatment for dilatory eustachian tube (ET) dysfunction. However, its efficacy in patients with both chronic suppurative otitis media (COM) and ET dysfunction remains unclear. The objective of the trial was to assess the efficacy and safety of BET versus medical management (MM) alone in adult patients with COM and chronic dilatory ET dysfunction, which was defined by a failed Valsalva maneuver. In this prospective, multicenter, randomized controlled trial, a total of 116 participants (121 ears) treated between January 2021 and June 2023 were randomly assigned (1:1) to receive either BET with MM or MM alone (fluticasone furoate nasal steroid spray). The short-term primary outcome was the normalization of the Valsalva maneuver at the 8-week follow-up. Secondary outcomes were improved Eustachian Tube Dysfunction Questionnaire- 7 (ETDQ-7) scores and decreased air-bone gap (ABG) analyzed at 8 weeks. Adverse events were monitored in both groups during the follow-up period. Among the 116 participants (121 ears), 60 participants (62 ears) received BET and 56 participants (59 ears) received MM alone. Demographics, baseline characteristics, ETDQ-7 scores, bone conduction thresholds, and ABG did not differ significantly between the groups. In the BET group, 46.8% (29/62, ears) achieved a successful Valsalva maneuver compared with 15.3% (9/59, ears) in the MM-only group (p<0.001). BET group (-6.2±9.4) showed greater subjective symptom improvement than the MM-only group (-2.6±8.6) regarding ETDQ-7 scores (p=0.028). ABG decreased more in the BET group (-5.8±11.4 dB) compared with the MM-only group (-1.2±10.5 dB) (p=0.023). No serious procedure-related or device-related adverse events occurred in either group during the 8-week follow-up. Our trial suggests that BET, combined with MM, demonstrated superiority over MM alone, along with its safety, in treating dilatory ET dysfunction in patients with COM.

Effect of endoscopic sinus surgery on eustachian tube function in adult patients with chronic rhinosinusitis

BackgroundChronic rhinosinusitis (CRS) is a frequent chronic heterogeneous inflammatory disease of the upper airways and paranasal sinuses persistent for ≥ 12 weeks causing considerable healthcare expenses and reduction of patients’ quality of life due to severe tiredness and disappointment as well as diminished cognitive function. CRS is commonly associated with eustachian tube (ET) dysfunction.Aim of the studyTo evaluate the effect of endoscopic sinus surgery on ET function in the form of (tympanogram, Valsalva maneuver, and total ET dysfunction questionnaire score), in adult patients with CRS.MethodThis non-randomized clinical trial study was conducted at the Otorhinolaryngology department, the Faculty of Medicine, Cairo University, on 40 patients > 18 years old, suffering from CRS with or without sinonasal polyposis who are indicated for endoscopic sinus surgery (ESS) and were recruited from Otorhinolaryngology department’s outpatient clinic in the period from November 2022 to June 2023. All selected patients were subjected to a full history taken, a full general examination, and a local otorhinolaryngology examination. Routine preoperative laboratory investigation including complete blood count (CBC), liver and kidney function tests, and coagulation profile. An electrocardiogram (ECG) examination was done routinely for all patients above 40 years old. Radiological examination included the following: preoperative CT nose and paranasal sinus, axial and coronal soft tissue cuts, and bone windows. Assessment of ET function was done using the ET dysfunction questionnaire (ETDQ-7), Valsalva maneuver, and tympanogram. ET function was reevaluated 6 weeks post-operative in the form of an ETDQ-7, Valsalva maneuver, and tympanogram.ResultsThe ages of selected patients ranged from 21 to 45 years old with mean ± SD = 30.98 ± 10.24 years old. 52.5% of patients were males. Our results showed a statistically significant postoperative improvement in the Valsalva maneuver and the tympanogram type of both ears compared to preoperative with a p-value < 0.001. Similar results were found regarding the assessment of ET function using ETDQ-7 items and the total score (15.35 ± 4.92 vs 26.12 ± 7.79 respectively) with p-value < 0.001.ConclusionA significant improvement in ET function in the form of tympanogram, Valsalva maneuver, and total ET dysfunction questionnaire score, following endoscopic sinus surgery in adult patients with CRS with or without sinonasal polyposis.

Goal-Directed Versus Self-Directed Valsalva Maneuver in Patients With Hypertrophic Cardiomyopathy on Cardiac Myosin Inhibitor Therapy.

The Valsalva maneuver is essential in evaluating left ventricular outflow tract (LVOT) obstruction in patients with hypertrophic cardiomyopathy (HCM). Traditionally, a self-directed Valsalva (SDV) maneuver is taught to patients using vague instructions such as "bear down." SDV is often not performed correctly leading to variable results and underestimation of the true provocable LVOT gradient. Alternatively, a standardized, goal-directed Valsalva (GDV) approach by maintaining an intraoral pressure 40mmHg for 10seconds or more provides a more objective, reproducible result. Accurate and reproducible LVOT gradient is key in the mavacamten algorithm for dose titration. The objective was to evaluate the clinical impact of the GDV compared to SDV in patients with obstructive HCM on mavacamten. In this prospective study, patients with obstructive HCM on mavacamten performed both an SDV and GDV. Peak LVOT gradient (pLVOTg) was measured at rest and using both provocative SDV and GDV maneuvers. A total of 69 patients were included with 203 total transthoracic echocardiograms (TTEs). Among initial postmavacamten TTEs, mean pLVOTg was significantly higher with GDV vs SDV (31mmHg vs 24mm Hg, P<0.01). When compared to SDV, GDV was associated with fewer patients maintaining pLVOTg≤20mmHg (29 [43%] vs 43 [63%], P<0.01) which decreased medication reductions and reduced TTE follow-up in the GDV cohort. GDV can significantly alter patient management in patients with obstructive HCM on cardiac myosin inhibitor therapy by reclassifying disease severity, preventing unnecessary dose reductions in medications, and reducing the burden of frequent TTEs.

Rational approach to fetal heart rate monitoring and management during the second stage of labor.

Second stage of labor is considered to be associated with an increased risk of intrapartum fetal hypoxic injury. This is due to a combination of several risk factors such as -the increased frequency, strength and duration of uterine contractions due to higher number and affinity of myometrial oxytocin receptors; -the Ferguson's reflex which leads to a reflex release of endogenous oxytocin in response of the distension of the cervix by descending fetal head in late stages of labor; maternal expulsive efforts with the Valsalva manoeuvre that may reduce maternal oxygenation, as well as reduce the venous return and maternal cardiac output due to increased intrathoracic pressure, winch may lead to reduced placental oxygenation; - and increased fetal intracranial pressure due to head compression leading to a potential decrease in fetal cerebral oxygenation. In addition, the umbilical cord often forms one or more loops around the fetal neck, which may get tightened as the head descends leading to an acute and intermittent cessation of fetal oxygenation. Operative interventions during the second stage of labor such as vacuum, forceps or emergency caesarean section may increase the risk of maternal and fetal trauma. Therefore, an accurate interpretation of the fetal heart rate changes by applying the knowledge of fetal pathophysiology is essential: to timely recognise the onset of fetal decompensation preventing intrapartum hypoxic-ischaemic brain injuries; to avoid erroneous monitoring of the maternal heart rate as fetal heart rate; and to abstain from unnecessary operative interventions due to misinterpretation of the significance of the observed fetal heart rate changes.

Efficacy of the party balloon inflation maneuver comparing with the valsalva maneuver for diagnosis of PFO and HOCM in transthoracic echocardiography

Abstract Background Previously, we reported clinical cases where the party balloon inflation manoeuvre (PBIM) proved more effective than the conventional Valsalva manoeuvre (VM) in diagnosing patent foramen ovale (PFO) and hypertrophic obstructive cardiomyopathy (HOCM). Additionally, increased venous return with PBIM was observed using hepatic vein flow assessed by transthoracic echocardiography (TTE). PBIM may offer enhanced visualisation of provocation, especially in cases where VM is insufficient. However, the haemodynamic evidence for the efficacy of PBIM with the optimal protocol compared to VM for PFO and HOCM has not been established. Purpose This study aimed to demonstrate the superiority of PBIM over the conventional VM and establish the optimal PBIM protocol for diagnosing PFO and HOCM through two experiments. Methods (Experiment 1) To understand the characteristics of party balloons, we measured the diameters and corresponding pressures of two commercially available balloons of different sizes (23 and 30 cm, referred to as a smaller balloon (SB) and a larger balloon (LB), respectively). (Experiment 2) We studied 23 healthy adult volunteers (physicians or sonographers, mean age 36 ± 10 years, 78% male), to investigate the haemodynamic effects of PBIM using protocols derived from the results of Experiment 1. Haemodynamic parameters, such as right ventricular inflow-velocity time integral (RV inflow-VTI) representing PFO haemodynamics and left ventricular end-diastolic diameter (LVDd) representing HOCM haemodynamics, were assessed by TTE during (for HOCM) and after (for PFO) the manoeuvre. These parameters were compared among PBIM, rest, and VM. Results Experiment 1: Figure 1 shows that both the SB and LB reached their peak pressures at diameters of 5 cm and 7 cm, respectively, and the pressures stabilised around a diameter of 15 cm. Experiment 2: Based on Experiment 1, four different PBIM protocols were used, SB inflated to 5 cm and 15 cm, and LB inflated to 7 cm and 15 cm. RV inflow-VTI increased in all PBIM protocols compared to VM (p &amp;lt;0.01). However, no significant differences were observed among all PBIM protocols (Figure 2A). LVDd decreased in all PBIM protocols compared to VM (p &amp;lt;0.01). Specifically, LVDd was significantly smaller when the SB was inflated to a diameter of 15 cm compared to the LB inflated to a diameter of 15 cm (p &amp;lt;0.05) (Figure 2B). Conclusions PBIM can effectively provoke the haemodynamic changes associated with PFO and HOCM compared to VM, potentially leading to a more accurate diagnosis. Notably, using a smaller balloon may be more advantageous for diagnosing HOCM. Figure 1 Figure 2

The efficacy of party balloon inflation maneuver to detect masked patent foramen ovale

Abstract Background The efficacy of transcatheter closure for patent foramen ovale (PFO) , which is considered a cause of cerebral infarction, has been reported. PFO often becomes apparent only during the Valsalva maneuver, making its diagnosis sometimes challenging. As a method to overcome inadequate Valsalva maneuvers, cases using the party balloon inflation maneuver have been reported. However, there are no verified reports on its actual effectiveness in daily clinical practice. Purpose To investigate the efficacy of party balloon inflation maneuver for revealing " masked " PFO. Methods We conducted a retrospective study to evaluate the efficacy of party balloon inflation maneuver during microbubble test transthoracic echocardiography in our hospital cases, which were diagnosed with embolic stroke of undetermined source and underwent the microbubble test with party balloon maneuver inflation between June 2023 and June 2024. Results A total of 74 patients（age 67 ± 15 years, 41 female) underwent microbubble test with party balloon inflation maneuver and were included. The average Rope score was 3.4 ± 1.9 because of high average age of patients. The party balloon inflation maneuver increased the grade of right to left shunt in 12 cases, leading to a diagnosis of a large right-to-left shunt. Moreover, the diagnosis rate of PFO and presence of the Eustachian valve with party balloon inflation maneuver were significantly higher than the conventional Valsalva maneuver with abdominal compression (diagnosis rate: 83.3 % vs 32.2 % ; p &amp;lt; 0.01 , Eustachian valve: 50.0 % vs 16.1 % ; p &amp;lt; 0.01) , but the rate of atrial septum aneurism was equivalent (17.7 % vs 25.0 % ; p = 0.69). Conclusions The party balloon inflation maneuver is an effective and excellent method to reveal " masked " PFO in dairy clinical practice.

Predictors of residual right/left shunt in patients undergoing percutaneous transcatheter patent foramen ovale closure; a new clue "inferior vena cava-patent foramen ovale angle"

Abstract Background Many different devices are currently used for percutaneous patent foramen ovale (PFO) closure (pPFOc). Current data for appropriate device selection are insufficient and confusing. The question of which device to choose during pPFOc is frequently posed by interventional cardiologist to echocardiographer, and it is a challenging question. The correct answer to this question is achieved by obtaining adequate anatomical occlusion. Purpose We aimed to determine the baseline anatomical predictors of PFO with residual right-to-left shunt (RLS) after pPFOc using transesophageal echocardiography (TEE). Methods Between May 2020 and May 2023, 103 patients who pPFOc for cryptogenic stroke were analysed. Patients were divided into two groups based on significant RLS. The presence of residual shunt was evaluated using contract echocardiography with bubble test at rest and during the Valsalva maneuver at 1, 6, and 12 months post-procedure. RLS were classified as follows: negative shunt (no bubble passage), mild shunt (1-9 bubbles), moderate shunt (10-20 bubbles), and severe shunt (&amp;gt;20 bubbles). At 12 months, patients with moderate and severe shunts were considered significant RLS [RLS (+)]. The implanted devices were also classified into three groups: Group 1 was used 23/25 mm OCCLUTECH devices, Group 2 was used 18x18 mm AMPLATZER devices, and Group 3 was used 27x30 mm OCCLUTECH and 30x30 AMPLATZER devices. Pre-procedural TEE was performed as part of our central protocol and anatomical features of PFO was evaluated (Figure-1). Logistic regression analysis was performed to assess predictors of post procedural RLS development. Results The procedure was successfully completed in all patients. In 21% of study population significant RLS was determined. During a median follow-up of 18 months, a patient died at 25th month due to metastatic testicular tumor, recurrent ischemic events were observed in 5 (5%) patients, and atrial fibrillation was detected in 3 (3%) patients. No significant difference was observed in the baseline clinical characteristics and laboratory parameters among of the patients. In addition to atrial septal aneurysm (ASA), aortic rim, tunnel width and length; IVC-PFO tunnel angle predicted RLS with a cut-off 11.3 (AUC:0.786, 64% sensitivity, 87% specificity) (Table-2, Figure-2). In individuals with significant RLS, longer and wider tunnel, shorter aortic rim, narrower inferior vena cava (IVC)-PFO tunnle angle and decreased tunnel length-left disc ratio were observed (Table- 1). IVC-PFO tunnel angle’s association with significant RLS was assessed individually with each conventional echo parameter (Figure- 3, Table -3). Conclusion IVC-PFO tunnel angle is a novel parameter and provides benefit to detect significant RLS in pPFOc patients. Figure 1 and Figure 3 Table 1,2,3 and Figure 2

The cardiac myosin inhibitor mavacamten reduces even extreme left ventricular outflow gradient in obstructive hypertrophic cardiomyopathy already after one week of treatment

Abstract Introduction Mavacamten is a selective, allosteric and reversible cardiac myosin inhibitor indicated for the treatment of symptomatic (NYHA II-III class) adult patients with obstructive [≥ 50 mmHg resting or provokable left ventricular outflow tract (LVOT) peak gradient] hypertrophic cardiomyopathy (HOCM). Patients and Methods Ten patients with HOCM [5 men (50%), mean age: 57±11 years) were treated with mavacamten. In 9 patients the resting or provoked gradient was &amp;gt;100 Hgmm. In addition to recording the main demographic, clinical parameters, complete standard and 2D-speckle tracking echocardiographic examination was performed in the patients after 1 week (1W) and 16 weeks (16W) of treatment. Results After 1W from initiation of mavacamten therapy, the resting peak LVOT gradient decreased by an average of -38 mmHg, from 113±36 mmHg to 75±36 mmHg (p=0.0028); which decreased further at 16W (mean difference -89 Hgmm, p=0.0002). The LVOT gradient provoked by the Valsalva maneuver decreased by -49 mmHg at 1W, from 150±43 mmHg to 107±50 mmHg (p=0.001), which further decreased at 16W (mean difference -107 Hgmm, p=0,0001). As the LVOT gradient decreased, patients' NTpBNP levels decreased at 1W by -690 pg/ml (p=0,0244), from 1270 (IQR: 636-2247) pg/ml to 756 (IQR: 377-1343) pg/ml, which further decreased at 16W (mean difference: -1103 pg/ml; p=0,0078). The ejection fraction and global longitudinal strain remained unchanged at 1W (EF: +0,7 %; p=0,6537; GLS: +0,5%; p=0.4303) and at 16W (EF: -2%; p=0.4499; GLS: 0%; p=0.9885). As the gradient decreased, the global work index and global constitutive work decreased at 1W (GWI: 2026±365 vs. 1675±382 mmHg%; p=0.0009; GCW: 2618±395 vs. 2091±468 mmHg%; p=0.0062) and at 16W (mean difference, GWI: : -406mmHg%; p=0,0062; GCW: -572 mmHg%; p=0,0018). Left atrial volume values showed a favorable regression trend at 1W (LAV: 137±30 vs. 124±25 ml; p=0.1513; LAVI: 71±13 vs. 64±12 ml/m2; p=0.1528) which became significant at 16W (mean difference, LAV: -35 ml; p=0,01; LAVI: -17 ml/m2, p=0,0092). Conclusion The direct myosin inhibitor mavacamten effectively reduces even extreme (&amp;gt;100 Hgmm) LVOTO gradients and has a beneficial effect on other structural and functional cardiac parameters. It has an effect even in the short term.

Comparison Valsalva maneuver and auriculotherapy on pain intensity of peripheral intravenous cannulation in adults: A randomized clinical trial.

Effective pain management during peripheral intravenous cannulation (PIVC) poses a significant challenge for medical practitioners in the emergency department. A range of non-pharmacological interventions have been advanced to address this concern. This study aimed to compare the effects of the Valsalva maneuver (VM) and auriculotherapy on pain intensity during PIVC in adults. A randomized clinical trial was conducted on 99 adult patients referred to Emergency department Hospital in Gonabad, Iran. Patients were randomly assigned into three groups VM (n = 33), auriculotherapy (n = 33), and control (n = 33). Pain levels were assessed using the Visual Analog Scale (VAS) immediately after PIVC. Data analysis was performed using SPSS version 25, with a significance level of less than 0.05. The mean pain scores in the VM, auriculotherapy, and control groups were 2.88 ± 3.81, 2.57 ± 3.45, and 7.13 ± 2.39, respectively. Kruskal-Walli's test revealed a significant difference among the groups (p < 0.001). Pairwise comparisons indicated no significant difference between VM and auriculotherapy groups in pain intensity (p = 0.67). However, significant differences were observed between the control group and the VM group (p < 0.001) as well as between the control group and the auriculotherapy group (p < 0.001). The results of this study demonstrate that both auriculotherapy and the Valsalva maneuver effectively reduce pain during PIVC in adults. Healthcare providers can consider incorporating these methods to help alleviate pain during PIVC procedures.

Clinical Significance of Anterograde Angiography for Preoperative Evaluation in Patients with Varicose Veins

Objective: To investigate the clinical significance of preoperative lower extremity venography in patients with varicose veins. Methods: From February 2019 to July 2023, 498 patients (583 diseased lower limbs) with lower limb varicose veins as the first symptom were selected and admitted to the Seventh People’s Hospital of Chongqing. Paracentesis of the deep veins of the lower extremities was performed in all affected limbs to observe the morphology of the deep veins from the ankle to the pelvis, the patency of the deep veins, and the reflux of contrast medium when the patients performed the Valsalva manoeuvre. The aetiology of varicose veins was analysed according to the imaging manifestations and individualised treatment plans were formulated according to the different aetiologies. Results: The imaging success rate of 583 diseased lower limbs was 100%, of which 285 (48.9%) were primary lower limb deep vein valve insufficiency, 186 (32%) were simple superficial varicose veins, 63 (10. 8%) were iliac vein compression syndromes, 41 (5%) were post-thrombotic syndromes of the deep veins of the lower limbs and the others (primary deep vein avascularity of the lower limbs, bifemoral venous malformations, congenital varicose vein osteohypertrophy syndrome, tumour compression, etc.) 8 articles (1.37%). Conclusion: The advantages of lower extremity deep vein bypass angiography are simple operation, low trauma, and high specificity, which can help to diagnose the aetiology of lower extremity varicose veins and guide the clinical treatment.

Trends in Neurosurgical Treatment for Chronic Subdural Hematoma in Germany: A National Survey.

Chronic subdural hematoma (cSDH) is a common neurosurgical condition of growing importance due to the aging population and increasing use of antithrombotic agents. Due to the lack of guidelines, great variability is observed in the treatment of cSDH. We conducted a multicenter, nationwide survey to assess the differences in treatment across Germany in the context of surgical practices discussed in the literature. A web-based survey was designed using the REDCap electronic data capture tool hosted at the Charité - Universitätsmedizin Berlin. The survey was divided into four parts: preoperative management and indication for surgery, perioperative management of medication, surgical technique, and postoperative management. The survey was distributed to German neurosurgical departments through the newsletter of the German Society of Neurosurgery and direct e-mail contact and could be answered by one member of each department between March 1 and May 31, 2023. Overall, representatives of 46 German neurosurgical departments completed the survey. Participants needed a mean time of 16:25 minutes (standard deviation [SD] ± 27:47 minutes) to complete the survey. The mean caseload of the participating departments was 1,831.5 (range: 300-6,000; SD ± 1,130.7) operations per year, including 87.8 procedures for cSDH (range: 15-300; SD ± 73.6). Evidence found in the literature regarding the performance of a burr hole craniotomy, use of a drain, passive drainage, removal of the drain 48 hours after surgery, and early mobilization after surgery was consistently implemented in the management of the surveyed departments. On the contrary, recommendations regarding the performance of surgery under local anesthesia, use of subgaleal drains, postoperative Valsalva maneuvers, and avoidance of postoperative computed tomography (CT) if possible were not universally implemented. This survey indicates that there is no consensus on the treatment of cSDH in Germany and that the steadily increasing evidence from clinical trials must be implemented in national and international guidelines. The development of tailored treatment strategies for older patients with multiple risk factors and comorbidities is of particular importance.

Branch retinal vein occlusion and Valsalva manoeuvre in wind instrument players and singers

ABSTRACT Clinical Relevance There are many recognised risk factors for retinal vein occlusions. It is plausible that musicians who play wind instruments or use their voice as their primary instrument may be at increased risk of branch retinal vein occlusions through repeated Valsalva manoeuvre. Background Repeated valsalva manoeuvres are commonly performed by musicians using high resistance wind instruments. This also true for singers. This case series illustrates a correlation between repeated Valsalva manoeuvres and retinal vein occlusion in three patients and explores the clinical and functional underlying mechanisms. Methods A retrospective review of three cases presenting to a private Ophthalmology clinic. Results Case 1 is an 85-year-old male, French Horn player and Case 2 is a 77-year-old male, bass-baritone singer each presented with a left-sided non-ischaemic branch retinal vein occlusion. Case 3 is a 79-year-old male Tenor presented with a left -sided ischaemic branch retinal vein occlusion. All cases were treated with intravitreal anti-vascular endothelial growth factor stabilising vision. Conclusion Repeated Valsalva manoeuvre as demonstrated in wind musicians and singers may play a role in pathogenies of branch retinal vein occlusions in susceptible individuals.

The Role of Eustachian Tube Dysfunction in Recurrent Chronic Otitis Media: A Cross-Sectional Study of Anatomical and Functional Variations.

Background/Objectives: Recurrent chronic otitis media (rCOM) is a major cause of hearing impairment, often linked to Eustachian tube (ET) dysfunction. Anatomical abnormalities, such as ET narrowing and obstructions, and functional impairments, including poor pressure regulation, play significant roles in rCOM recurrence. This study aimed to (1) identify anatomical variations of the ET in patients with rCOM using high-resolution imaging; (2) evaluate ET functional status using tympanometry, tubomanometry, and ET function tests; and (3) assess the correlation between anatomical variations and functional impairments in predicting rCOM recurrence. Methods: A cross-sectional study was conducted on 212 patients with rCOM and 212 controls. High-resolution CT and MRI were used to assess ET anatomy, while functional status was evaluated using tympanometry, tubomanometry, and Valsalva maneuver tests. Statistical analyses, including t-tests, Pearson correlation, and Cox proportional hazards models, were applied to examine the relationship between anatomical and functional impairments and rCOM recurrence. Results: Significant anatomical differences were observed in the rCOM group, including ET narrowing (24.53% vs. 11.32%, p = 0.014) and curvature (32.08% vs. 14.15%, p < 0.001). Functional impairments were also more prominent in rCOM patients, with higher ET opening pressure (120.56 ± 14.34 dPa vs. 85.78 ± 12.98 dPa, p < 0.001) and lower Valsalva maneuver success rates (62.32% vs. 89.56%, p < 0.001). Cox regression indicated that anatomical and functional impairments significantly predicted faster recurrence (HR for tympanometry peak pressure = 1.56, p < 0.001). Conclusions: The ETs anatomical and functional impairments are significant predictors of rCOM recurrence. A combined assessment of these factors can improve diagnostic accuracy and guide more targeted interventions to prevent recurrence.

Ultrasound Quantitative Assessment of the Effects of Yoga on Early Postpartum Pelvic Organ Position Recovery.

This study examines the effectiveness of yoga intervention on the early postpartum recovery of pelvic organ positions. A prospective study was conducted from May to November 2020, involving women who had vaginal deliveries and underwent pelvic floor ultrasound examinations. The control group received no intervention, whereas the experimental group participated in weekly 60-min yoga sessions from 1week to 3months postpartum. Pelvic organ positions, including the bladder neck, uterus, and rectal ampulla, were measured via ultrasound at rest and during the Valsalva maneuver at 42days and 3months postpartum. The effectiveness of yoga was assessed using t tests. A total of 128 women participated, with 66 in the control group and 62 in the experimental group. There were no significant differences between groups in age, parity, BMI, or fetal weight (p > 0.05). At 42days postpartum, there were no significant changes in bladder neck and uterine positions at rest, except for a significant decrease in rectal ampulla position in the control group (p < 0.01). During the Valsalva maneuver, the experimental group showed significant improvement in all pelvic organ positions at 3months compared with 42days (p < 0.001), with better outcomes than the control group (p < 0.001). Yoga intervention supports early postpartum recovery of pelvic organ positions.

Reversion of Supra-Ventricular Tachycardia Through High Positive End-Expiratory Pressure During Mechanical Ventilation in Critically Ill Patients.

The Valsalva manoeuvre is widely recognised for its effectiveness in reverting supra-ventricular tachycardia (SVT) in patients with good coordination. However, this is not applicable in sedated ventilated patients and there is a dearth of literature regarding the application of Valsalva in unconscious patients on mechanical ventilation. The authors, for the first time, present a novel non-pharmacological method to treat SVT in critically ill patients on mechanical ventilation, employing the high positive end-expiratory pressure (PEEP) technique. This method successfully reverted SVT in two patients. While the exact mechanism remains unconfirmed, it is believed to be similar to that of the Valsalva manoeuvre. Further research is needed to validate this technique and determine the optimal ventilator settings, including the PEEP threshold, for such cases. Key Words: Valsalva manoeuvre, Supraventricular tachycardia, Positive end-expiratory pressure, Mechanical ventilation.

C1 root decompression as a therapeutic target in non-suboccipital non-Valsalva related headache associated with Chiari I malformation

Headache (HA) is the most common symptom impacting the quality of life of patients with Chiari I malformation. While HAs typically present in the occipital or suboccipital regions, and induced by Valsalva maneuver, complex migraine-like HAs referring to frontal or orbital regions also occur. Our study explores the therapeutic potential of C1 nerve root decompression in addition to increasing intracranial compliance in patients with Chiari I malformation. We retrospectively analyzed cases operated on for Chiari I malformation, focusing on patients with nonsuboccipital, non-Valsalva induced HAs. Preoperative and postoperative visual analog scale scores and HA frequency were recorded. Surgical technique involved suboccipital craniectomy, C1 laminectomy, cerebellar tonsil reduction, and C1 root decompression. Twelve patients (10 females, 2 males) aged 22-52 years were included. Preoperative mean visual analog scale score was 8, which improved to 2 or less in 11 patients postoperatively. The mean HA frequency decreased significantly. Our findings suggest that C1 root compression contributes to atypical HAs in Chiari I malformation and that C1 root decompression may improve surgical outcomes.