[Clinical application of the dynamic adenoidal hypertrophy ratio in the evaluation of illness severity in children with OSAHS]

Objective:To evaluate application value of the dynamic adenoidal/hypertrophy (A/N) ratio in children with OSAHS by analyzing the correlation between the A/N ratio at the different respiratory phases and the index of polysomnography.Method:Fifty-one childrens, with simple hypertrophic adenoids, were diagnosed as OSAHS. Magnetic resonance imaging (MRI) with respiratory gating technology were used to scan the upper airway of children during sleep at the early, middle and end phases of respiratory cycle, and measure adenoidal hypertrophy ratio in different respiratory phases. The correlation analysis was performed between the A/N ratio in different respiratory phases and the index of polysomnography (AHI and LaSO2). Finally, via ROC curve and Kappa analysis, the critical value and diagnosis accordance rate of A/N ratio in illness severity evaluation of children with OSAHS were confirmed.Result:At the 6 respiratory phases, the A/N ratios showed significantly positive correlations with AHI (All P< 0.01). There was a highest coefficient between the end-expiratory A/N ratio and AHI (r= 0.559 4). In addition, the optimal cut-off point of A/N ratio between slight-moderate and severe OSAHS was 0.834. The diagnosis accuracies of the end-expiratory A/N ratio in severe and slight moderate OSAHS were 81% and 84%, respectively.Conclusion:MRI with respiratory gating technology obtaining dynamic A/N ratio might be an important method of imaging diagnosis of children OSAHS, and the end expiratory A/N ratio is expected to become a classification index of slight moderate and severe children OSAHS.

Duplex Ultrasound Scanning for Chronic Venous Disease: I. Techniques for Examination of the Crural Veins

Objective:

To describe a practical technique to reliably find and study crural veins by duplex ultrasound scanning.

Design:

Prospective scanning of patients referred for evaluation of possible chronic deep venous insufficiency.

Setting:

A non-invasive vascular diagnostic laboratory in Melbourne, Australia.

Patients:

A study of 1340 legs in 917 consecutive patients referred with primary or recurrent varicose veins, or for evaluation of possible deep venous disease causing aching or swelling in the legs.

Interventions:

Examination of the crural veins by duplex ultrasound scanning.

Main outcome measure:

Identification of all three sets of crural veins.

Results:

Rates for detecting the posterior tibial, anterior tibial and peroneal veins were 97%, 92% and 91% respectively and all three were observed in 91%. If the last 1227 legs studied by colour-Doppler duplex ultrasound are considered, the rates for detection were 98%, 96% and 96% respectively.

Conclusion:

Examination of the crural veins can be a part of routine duplex ultrasound scanning in patients referred with suspected venous disease.

Duplex Ultrasound Scanning for Chronic Venous Disease: Recurrent Varicose Veins in the Thigh after Surgery to the Long Saphenous Vein

Objective:

To use duplex ultrasound scanning to compare limbs with recurrent and primary varicose veins and to identify connections between deep veins and recurrences.

Setting:

A non-invasive vascular laboratory in Melbourne, Australia.

Patients:

A study of 779 limbs with recurrent varicose veins previously treated by ligation or stripping of the long saphenous vein and 1521 limbs with primary varicose veins.

Main outcome measures:

Connections between deep veins and recurrent varices, reflux in superficial and deep veins, and outward flow in perforators as demonstrated by duplex ultrasonography.

Results:

Recurrence was due to reflux in the long saphenous territory in 71.8%, short saphenous reflux alone in 14.7% or outward flow in calf perforators without saphenous reflux in 5.2%, while no source was detected in 8.3%. Limbs with recurrent veins in the long saphenous territory were compared with limbs with primary varicose veins; there was more frequent outward flow in thigh perforators (25.2% vs. 16.2%) but no difference for deep reflux (20.7% vs. 17.5%) or outward flow in calf perforators (56.8% vs. 53.1%). The source for recurrence in the long saphenous territory was from a single large connection in the groin in 46.3%, multiple smaller proximal connections in a further 46.3%, or thigh perforators in 7.4%. The destination was to an intact long saphenous vein in 33.7%, major tributaries in 28.7% or to other varices in 37.6%. Limbs known to have been treated by long saphenous ligation alone were compared with those known to be treated by long saphenous ligation and stripping; the source was more likely to be from a single large vein in the groin (60.3% vs. 39.9%) and the destination was more likely to be an intact long saphenous vein or major tributary (75.0% vs. 55.2%).

Conclusions:

Duplex ultrasound scanning detected the source of recurrent varicose veins in over 90% of patients and demonstrated whether there were single large or multiple smaller connections in the veins affected, and this helps to select the most appropriate treatment. Recurrence after stripping the long saphenous vein was more likely to be due to multiple small connections passing to scattered varices and this may allow more simple treatment by injection sclerotherapy rather than repeat surgery.

The role of middle calyx puncture in percutaneous nephrolithotomy: relative factors and choice considerations

Percutaneous nephrolithotomy (PCNL) is a well established procedure for management of renal calculi. It is generally believed that the access to the renal pelvic system via the desired calyx is the most crucial step during the whole procedure. The adequacy of the access directly influences the success and complication rates of PCNL. Traditionally, a lower pole access was routinely performed for less complication. Upper calices are also preferred for access in a given condition with large and complex calculi. However, the middle calices access is seldom selected. In aim to provide the reader some advantages of middle pole approach and a broaden horizon in determining the strategy of renal puncture, the present review describes the anatomical basis of the percutaneous tract. It provides a literature review of the success rate and efficiency of middle calyx access alone with the advantage of this approach, especially in dealing with large and complex stones.

Duplex Ultrasound Scanning for Chronic Venous Disease: The Frequency of Reflux in the Crural Veins

Objective:

To use duplex ultrasound scanning to determine the frequency of reflux in crural veins and its relation to the presentation, reflux in superficial and other deep veins, and outward flow in perforators in patients referred for assessment of chronic venous disease.

Design:

Scanning of superficial, deep and perforator veins.

Setting:

A vascular diagnostic laboratory in Melbourne, Australia.

Patients:

A study of 2590 lower limbs in 1684 consecutive patients.

Main outcome measure:

The frequency of reflux in crural veins.

Results:

The posterior tibial, anterior tibial and peroneal veins were identified in 98%, 95% and 95% and reflux was observed in 5%, 2% and 3%, respectively. Posterior tibial reflux was twice as frequent as reflux in the anterior tibial and/or peroneal veins alone. Posterior tibial reflux was significantly more frequent if there were clinical complications (19% of limbs with previous ulceration or lipodermatosclerosis), short saphenous reflux alone (8%) or both long and short saphenous reflux (11%), popliteal reflux (28%), or outward flow in medial calf perforators (6%) ( p<0.0001 for each). Posterior tibial reflux was no more frequent if there was Jong saphenous reflux alone or femoral reflux alone. Anterior tibial and/or peroneal reflux without posterior tibial reflux was not significantly related to the clinical presentation or reflux at any other site.

Conclusions:

The association of posterior tibial reflux with clinical complications, short saphenous reflux (alone or associated with long saphenous reflux), popliteal reflux or outward flow in perforators observed with duplex scanning contrasted with the lack of any such associations for anterior tibial or peroneal reflux without posterior tibial reflux. Scanning the anterior tibial and peroneal veins may add little to the examination.

Clinical and vascular laboratory determinants for outcome after infrainguinal atherectomy

Three surgeons performed 180 atherectomy procedures in 161 patients using the Transluminal Extraction Catheter in 144 and the Auth Rotablator in 36. The primary patency rate was 55% at 1 year and 46% at 2 years, and failure was caused by stenosis in 28 (15.6%) and occlusion in 61 (33.7%) limbs. Multivariate Cox regression analysis showed significantly better outcome if the indication was claudication, the lesion was short or there was associated stenting. Vascular laboratory surveillance was performed in 93 limbs in 83 patients. Cox regression analysis in this subgroup also showed a significant relationship between outcome and the maximum peak systolic velocity from a duplex scan at the last study performed. Receiver operating characteristics curves showed that a raised maximum peak systolic velocity best predicted late failure (sensitivity 84%, specificity 66% for > 200 cm/s; sensitivity 72%, specificity 84% for > 250 cm/s); the velocity ratio at the stenosis to that in the segment above or the resting ankle/brachial pressure index were less predictive. For 50 procedures studied in the vascular laboratory which remained successful to the end of the study, maximum peak systolic velocities were > 250 cm/s from the first postoperative study, suggesting residual stenosis in 6%, or increased to become > 250 cm/s by the last study, suggesting recurrent stenoses in 12%. For 43 procedures which were studied and later failed, velocities were > 250 cm/s from the first test in 26% or increased to > 250 cm/s by the last test before failure in 40%. Vascular laboratory surveillance helps to predict outcome after atherectomy. Failure may be a result of residual disease from the time of the procedure or from restenosis. The apparent high incidence of clinically manifest or developing stenoses raises doubts as to the benefit of atherectomy over balloon dilatation alone.

Duplex ultrasonography scanning for chronic venous disease: patterns of venous reflux

PURPOSE

Patterns of flow in superficial and deep veins and outward flow in medial calf perforators were studied by duplex ultrasonography scanning in 1653 lower limbs in 1114 consecutive patients. This study compares results in 776 limbs with primary uncomplicated varicose veins with those in 166 limbs with the complications of lipodermatosclerosis or past venous ulceration.

METHODS

Duplex scanning determined whether superficial and deep veins were occluded or showed reflux and whether outward flow occurred in medial calf perforators with calf muscle contraction.

RESULTS

Two proximal deep veins were occluded. When limbs with primary uncomplicated varicose veins, lipodermatosclerosis, or past ulceration were compared, superficial reflux alone was seen in 55%, 39%, and 38%, deep reflux alone was seen in 2%, 7%, and 8%, and combined superficial and deep reflux was seen in 18%, 34%, and 48%, respectively. Superficial reflux affected the long saphenous system alone in 58%, 57%, and 40%, the short saphenous system alone in 18%, 18%, and 26%, and both the long and short saphenous systems in 24%, 25%, and 34%, respectively. Limbs with ulceration more frequently showed superficial reflux (p < 0.05), and all limbs with complications more frequently showed short saphenous reflux (p < 0.05) and deep reflux (p < 0.01) specifically in the posterior tibial veins (p < 0.01). Outward flow was seen in medial calf perforators in 57%, 67%, and 66%, respectively; it occurred more frequently in all limbs with complications (p < 0.05). Isolated outward flow in perforators without superficial or deep reflux was seen in 10%, 10%, and 2%, respectively.

CONCLUSIONS

Most limbs with complications had superficial reflux either alone or combined with deep reflux, and few had deep reflux alone. Reflux was more frequent in posterior tibial veins for limbs with complications compared with those with uncomplicated primary varicose veins. Outward flow in perforators was common in limbs with complications and with uncomplicated primary varicose veins, but isolated outward flow in perforators was uncommon. Treatment directed to the superficial veins alone may be sufficient for most patients with complications.