Real-time feedback on chest compression efficacy by hands-free carotid Doppler in a porcine model

Aim

Current guidelines for cardiopulmonary resuscitation (CPR) recommend a one-size-fits-all approach in relation to the positioning of chest compressions. We recently developed RescueDoppler, a hands-free Doppler ultrasound device for continuous monitoring of carotid blood flow velocity during CPR. The aim of the present study is to investigate whether RescueDoppler via real-time hemodynamic feedback, could identify both optimal and suboptimal compression positions.

Methods

In this model of animal cardiac arrest, we induced ventricular fibrillation in five domestic pigs. Manual chest compressions were performed for ten seconds at three different positions on the sternum in random order and repeated six times. We analysed Time Average Velocity (TAV) with chest compression position as a fixed effect and animal, position, and sequential time within animals as random effects. Furthermore, we compared TAV to invasive blood pressure from the contralateral carotid artery.

Results

We were able to detect changes in TAV when altering positions. The positions with the highest (range 19 to 48 cm/s) and lowest (6-25 cm/s) TAV were identified in all animals, with corresponding peak pressure 50-81 mmHg, and 46-64 mmHg, respectively. Blood flow velocity was, on average, highest at the middle position (TAV 33 cm/s), but with significant variability between animals (SD 2.8) and positions within the same animal (SD 9.3).

Conclusion

RescueDoppler detected TAV changes during CPR with alternating chest compression positions, identifying the position yielding maximal TAV. Future clinical studies should investigate if RescueDoppler can be used as a real-time hemodynamical feedback device to guide compression position.

Evaluation of arteriovenous fistula for hemodialysis with a new generation digital stethoscope: a pilot study

BACKGROUND AND AIMS

The management of complications of arteriovenous fistula (AVF) for hemodialysis, principally stenosis, remains a major challenge for clinicians with a substantial impact on health resources. Stenosis not infrequently preludes to thrombotic events with the loss of AVF functionality. A functioning AVF, when listened by a stethoscope, has a continuous systolic-diastolic low-frequency murmur, while with stenosis, the frequency of the murmur increases and the duration of diastolic component decreases, disappearing in severe stenosis. These evidences are strictly subjective and dependent from operator skill and experience. New generation digital stethoscopes are able to record sound and subsequently dedicated software allows to extract quantitative variables that characterize the sound in an absolutely objective and repeatable way. The aim of our study was to analyze with an appropriate software sounds from AVFs taken by a commercial digital stethoscope and to investigate the potentiality to develop an objective way to detect stenosis.

METHODS

Between September 2022 and January 2023, 64 chronic hemodialysis (HD) patients were screened by two blinded experienced examiners for recognized criteria for stenosis by Doppler ultrasound (DUS) and, consequently, the sound coming from the AVFs using a 3 M™ Littmann® CORE Digital Stethoscope 8570 in standardized sites was recorded. The sound waves were transformed into quantitative variables (amplitude and frequency) using a sound analysis software. The practical usefulness of the core digital stethoscope for a quick identification of an AVF stenosis was further evaluated through a pragmatic trial. Eight young nephrologist trainees underwent a simple auscultatory training consisting of two sessions of sound auscultation focusing two times on a "normal" AVF sound by placing the digital stethoscope on a convenience site of a functional AVF.

RESULTS

In 48 patients eligible, all sound components displayed, alone, a remarkable diagnostic capacity. More in detail, the AUC of the average power was 0.872 [95% CI 0.729-0.951], while that of the mean normalized frequency was 0.822 [95% 0.656-0.930]. From a total of 32 auscultations (eight different block sequences, each one comprising four auscultations), the young clinicians were able to identify the correct sound (stenosis/normal AVF) in 25 cases, corresponding to an overall accuracy of 78.12% (95% CI 60.03-90.72%).

CONCLUSIONS

The analysis of sound waves by a digital stethoscope permitted us to distinguish between stenotic and no stenotic AVFs. The standardization of this technique and the introducing of data in a deep learning algorithm could allow an objective and fast method for a frequent monitoring of AVF.

Evaluation and patient experience of wireless noninvasive fetal heart rate monitoring devices

INTRODUCTION

In clinical practice, fetal heart rate monitoring is performed intermittently using Doppler ultrasound, typically for 30 minutes. In case of a non-reassuring heart rate pattern, monitoring is usually prolonged. Noninvasive fetal electrocardiography may be more suitable for prolonged monitoring due to improved patient comfort and signal quality. This study evaluates the performance and patient experience of four noninvasive electrocardiography devices to assess candidate devices for prolonged noninvasive fetal heart rate monitoring.

MATERIAL AND METHODS

Non-critically sick women with a singleton pregnancy from 24 weeks of gestation were eligible for inclusion. Fetal heart rate monitoring was performed during standard care with a Doppler ultrasound device (Philips Avalon-FM30) alone or with this Doppler ultrasound device simultaneously with one of four noninvasive electrocardiography devices (Nemo Fetal Monitoring System, Philips Avalon-Beltless, Demcon Dipha-16 and Dräger Infinity-M300). Performance was evaluated by: success rate, positive percent agreement, bias, 95% limits of agreement, regression line, root mean square error and visual agreement using FIGO guidelines. Patient experience was captured using a self-made questionnaire.

RESULTS

A total of 10 women were included per device. For fetal heart rate, Nemo performed best (success rate: 99.4%, positive percent agreement: 94.2%, root mean square error 5.1 BPM, bias: 0.5 BPM, 95% limits of agreement: -9.7 - 10.7 BPM, regression line: y = -0.1x + 11.1) and the cardiotocography tracings obtained simultaneously by Nemo and Avalon-FM30 received the same FIGO classification. Comparable results were found with the Avalon-Beltless from 36 weeks of gestation, whereas the Dipha-16 and Infinity-M300 performed significantly worse. The Avalon-Beltless, Nemo and Infinity-M300 closely matched the performance of the Avalon-FM30 for maternal heart rate, whereas the performance of the Dipha-16 deviated more. Patient experience scores were higher for the noninvasive electrocardiography devices.

CONCLUSIONS

Both Nemo and Avalon-Beltless are suitable devices for (prolonged) noninvasive fetal heart rate monitoring, taking their intended use into account. But outside its intended use limit of 36 weeks' gestation, the Avalon-Beltless performs less well, comparable to the Dipha-16 and Infinity-M300, making them currently unsuitable for (prolonged) noninvasive fetal heart rate monitoring. Noninvasive electrocardiography devices appear to be preferred due to greater comfort and mobility.

Enhancing endometrial receptivity in FET cycles: exploring the influence of endometrial and subendometrial blood flow along with endometrial volume

Introduction

Fetal health and a receptive and healthy endometrium are two essential factors in achieving successful implantation. If the endometrium is unreceptive, postponing the transfer cycle to a suitable time can enhance the chances of pregnancy. This study aims to assess the impact of endometrial and sub-endometrial blood flows measured by Doppler ultrasound, as well as endometrial volume, on endometrial receptivity in frozen embryo transfer (FET) cycles.

Methods

112 patients with a mean age of 33.93 ± 4.93 years underwent in vitro fertilization (IVF). Serum β-hCG level was used to confirm pregnancy, and among the participants, 50 (44.6%) achieved pregnancy after IVF.

Results

The study results revealed a significant difference in endometrial blood flow between the pregnant and non-pregnant groups, with a higher pregnancy rate observed in participants exhibiting multi-focal and spare endometrial blood flows (p < 0.05). Furthermore, there was a notable association between endometrial blood flow and pregnancy outcome, as indicated by higher ongoing pregnancy rates in those with multi-focal and spare endometrial blood flows (p < 0.05). However, no significant differences were observed in endometrial variables such as volume, length, width, thickness, and pattern between the pregnant and non-pregnant groups. Additionally, contextual parameters showed no significant relationship with pregnancy outcome (p > 0.05). The study also found that endometrial measurement indices did not have a significant impact on pregnancy outcomes, with no significant differences observed between the groups (p > 0.05).

Conclusion

In conclusion, endometrial blood flow is crucial for a successful pregnancy after IVF, while the predictive value of the endometrial volume is limited for pregnancy outcomes.

Assessment of anatomic variations of the brachial artery bifurcation using vascular Doppler ultrasound: a cross-sectional study

Background

Anatomical variations in arteries of the upper limb, such as presence of an accessory brachial artery, are common and widely described in the literature, mainly in cadaveric studies, but it is now possible to diagnose them using vascular Doppler ultrasound.

Objectives

To identify the incidence of accessory brachial artery using vascular Doppler ultrasound and compare the findings with cadaveric studies.

Methods

This was a prospective study that examined 500 upper limbs of 250 volunteers assessed with vascular Doppler ultrasound using the Sonosite Titan portable ultrasound machine.

Results

15.6% of the participants in our study had the accessory brachial artery anatomical variation. Our percentage is in line with the average rates found in cadaveric studies, which ranged from 0.2% to 22%. Being aware of this variation is fundamental in procedures such as peripheral venipuncture, arteriovenous fistula creation, catheterization, forearm flaps, emergency surgeries on the limb and even correction of fractures by cast.

Conclusions

The accessory brachial artery is a frequent variant in the upper limb. The percentage of individuals with an accessory brachial artery in our study was 15.6%, which agrees with data from the literature on cadaveric studies.

Value of carotid corrected flow time or changes value of FTc could be more useful in predicting fluid responsiveness in patients undergoing robot-assisted gynecologic surgery: a prospective observational study

Background

The aim of this study was to evaluate the ability of point-of-care Doppler ultrasound measurements of carotid corrected flow time and its changes induced by volume expansion to predict fluid responsiveness in patients undergoing robot-assisted gynecological surgery.

Methods

In this prospective study, carotid corrected flow time was measured using Doppler images of the common carotid artery before and after volume expansion. The stroke volume index at each time point was recorded using noninvasive cardiac output monitoring with MostCare. Of the 52 patients enrolled, 26 responded.

Results

The areas under the receiver operating characteristic curves of the carotid corrected flow time and changes in carotid corrected flow time induced by volume expansion were 0.82 and 0.67, respectively. Their optimal cut-off values were 357 and 19.5 ms, respectively.

Conclusion

Carotid corrected flow time was superior to changes in carotid corrected flow time induced by volume expansion for predicting fluid responsiveness in this population.

Spectral Doppler Parameters of Fetal Main Branch Pulmonary Artery at 20 to 40 Weeks of Gestation: Reference Ranges and Percentile Calculators

BACKGROUND

The published reference ranges for Doppler parameters of the fetal pulmonary artery (PA) are usually derived from small sample sizes with no practical standard score or percentile ranking, which hinders systematic comparisons of Doppler figures across different gestational ages (GAs). This study aimed to establish comprehensive reference ranges and provide a percentile ranking solution for key spectral Doppler parameters.

METHODS

This is a cross-sectional study of 465 uncomplicated singleton pregnancies during 20 to 40 weeks of gestation. Spectral waveforms of the fetal main branch PA were obtained with a pulsed-wave Doppler interrogation site within 5 mm from the vascular origin. Fifteen spectral Doppler parameters were identified. Associations between these parameters with GA and fetal heart rate were assessed and used to develop percentile calculators via different statistical models. The root mean squared error of each model was calculated to determine the best performance solution.

RESULTS

Acceptable spectral waveforms were obtained for 94.1% (438/465) of the fetuses. All Doppler parameters except pulsatility index, manually traced pulsatility index, peak systolic velocity, and time to systolic notch/acceleration time ratio were significantly correlated with GA, while acceleration time, ejection time, time to systolic notch, peak early-diastolic reversal flow, and peak early-diastolic reversal flow/peak systolic velocity ratio were additionally significantly correlated with fetal heart rate. Support vector machine models with radial basis kernel yield the best percentile estimation (root mean squared error of 2.17-4.08 and R2 of >0.98). Furthermore, the top 5% and bottom 5% outliers could be identified with positive predictive values of 0.71 to 0.97. An online user interface of percentile calculators is available at https://github.com/cmb-chula/fetoPAD.

CONCLUSIONS

This study presents normal reference ranges and percentile calculators for 15 spectral Doppler parameters of the fetal main branch PA, some of which have not been published. The estimated percentiles enhance comparison and outlier detection of the spectral Doppler figures among fetuses at different GAs.

Cost-effectiveness analysis of the diagnosis of temporal arteritis

Temporal arteritis (TA) is the most common form of systemic vasculitis. Its diagnosis is based on criteria proposed by the American College of Rheumatology (1990), and its treatment is high-dose corticosteroids. Our objective is to assess the cost of diagnosing TA, and secondarily, cost-effective analysis of different diagnostic strategies (clinical, biopsy, doppler ultrasound) and therapeutic strategies (corticosteroid suspension).

MATERIAL AND METHOD

Observational, retrospective study has been carried out on patients with AT (2012-2021). Demographic data, comorbidities, signs and symptoms suggestive of AT were collected. AT was diagnosed with a score ≥ 3 according to American College of Rheumatoloy criteria (ACR-SCORE). The costs of diagnosis and treatment modification were analysed.

RESULTS

Seventy-five patients have been included, median age 77 (46-87) years. Headache, temporal pain and jaw claudication were significant for the diagnosis of TA. Patients with a halo on Doppler ultrasound and a positive biopsy have significantly elevated ESR and CRP compared to patients who do not. The cost of the AT diagnosis was 414.7 euros/patient. If we use ACR-SCORE ≥ 3-echodoppler it is 167.2 є/patient (savings 59.6%) and ACR-SCORE ≥ 3-biopsy 339.75 є/patient (savings 18%). If the corticosteroid was removed and a biopsy was performed, 21.6 є/patient (94.7% savings), if the corticosteroid was removed and Doppler ultrasound was performed, 10.6 є/patient (97.4% savings).

CONCLUSIONS

Headache, temporary pain and jaw claudication are predictors of AT. Elevated ESR and CRP are predictors of positive biopsy and presence of halo on ultrasound. The uses of ACR-SCORE ≥ 3 with Doppler ultrasound or biopsy, and with corticosteroid suspension, are cost-effective.

Utility of nifedipine use for Doppler ultrasound early after liver transplantation to predict short-term complications and long-term outcomes

PURPOSE

To evaluate the response to nifedipine administration measured by changes in hepatic arterial (HA) flow on post-operative Doppler ultrasound (US) to predict short-term complications and long-term outcomes in liver transplant (LT) patients.

METHODS

Patients who underwent LT with post-operative Doppler US within 3 days between 1 January 2005 and 31 December 2015 were included in this retrospective single center study. The patients who received and did not receive nifedipine during the Doppler US comprised the study and control groups, respectively. A positive response to nifedipine was defined as the detection of HA flow when none was present initially or a reduction in HA resistive index (RI) ≥ 0.1 after nifedipine administration. The rates of re-transplantation, re-operation, percutaneous intervention (PCI), and overall survival (OS) were recorded. Cox proportional hazards regression was used to evaluate the association of clinic-demographic variables and Doppler findings with the outcome measures.

RESULTS

444 LT patients (305 M/139F, mean age 51.7 ± 17.4 years, mean interval between LT-Doppler US 1.12 ± 0.9 days) are presented. 220 patients comprised the nifedipine study group [n = 157/220 (71.4%) responder, n = 63/220 (28.6%) nonresponder] and 224 patients comprised the control group. There was no difference in re-transplantation or PCI rates between the groups (all p-values ≥ 0.2 and ≥ 0.08, respectively). The responder group had a lower rate of re-operation vs. the control group (15.9% vs. 24.1%, p = 0.03) and nonresponder group (15.9% vs. 31.8%, p = 0.004). 1-year and 2-year OS were similar between the groups (all p-values > 0.37).

CONCLUSION

Short-term complication rates and long-term outcomes for patients with liver transplant who responded to nifedipine administration on Doppler US are similar to those who did not require nifedipine administration. A lack of response to nifedipine was associated with a higher re-operation rate.

Accuracy of maximal acceleration time of pedal arteries to diagnose critical limb-threatening ischemia

INTRODUCTION

Maximal acceleration time of distal arteries of the foot (ATmax) is correlated to ankle-brachial index (ABI) and toe-brachial index (TBI), and seems very promising in diagnosing severe peripheral artery disease (PAD) and especially critical limb-threatening ischemia (CLTI). Our goal was to confirm the cut-off value of 215 ms to predict a toe pressure (TP) ⩽ 30 mmHg.

METHODS

A 4-month retrospective study was conducted on patients addressed for suspicion of PAD. Demographic data, ABI, TBI, and Doppler ultrasound scanning parameters of the dorsal pedis and lateral plantar arteries (DPA and LPA) were recorded.

RESULTS

A total of 137 patients with 258 lower limbs were included. ATmax was highly correlated to TBI (r = -0.89, p < 0.001). With the cut-off value of 215 ms, ATmax was effective to diagnose TP ⩽ 30 mmHg with a sensitivity of 93% [95% CI 77-99], a specificity of 96% [95% CI 92-98], a positive predictive value of 73% [95% CI 56-86], a negative predictive value of 99% [95% CI 97-100], and an area under the receiver operating characteristics curve of 0.99 [95% CI 0.98-1.00]. ATmax also showed promising results to rule out PAD in healthy patients.

CONCLUSION

ATmax is a reliable diagnostic tool to diagnose low TP and could be a new easily performed hemodynamic criterion for diagnosis of CLTI.

The association between discordant umbilical arterial resistance in growth-restricted fetuses and adverse outcomes

BACKGROUND

Assessing the umbilical artery pulsatility index via Doppler measurements plays a crucial role in evaluating fetal growth impairment.

OBJECTIVE

This study aimed to investigate perinatal outcomes associated with discordant pulsatility indices of umbilical arteries in fetuses with growth restriction.

STUDY DESIGN

In this retrospective cohort study, all singleton pregnancies were included if their estimated fetal weight and/or abdominal circumference fell below the 10th percentile for gestational age (2017-2022). Eligible cases included singleton pregnancies with concurrent sampling of both umbilical arteries within 14 days of birth at the ultrasound evaluation closest to delivery. The exclusion criteria included births before 22 weeks of gestation, evidence of absent or reverse end-diastolic flow in either umbilical artery, and known fetal genetic or structural anomalies. The study compared cases with discordant umbilical artery pulsatility index values (defined as 1 umbilical artery pulsatility index at ≤95th percentile and the other umbilical artery pulsatility index at >95th percentile for gestational age) to pregnancies where both umbilical artery pulsatility indices had normal pulsatility index values and those with both umbilical arteries displaying abnormal pulsatility index values. The primary outcome assessed was the occurrence of composite adverse neonatal outcomes. Multivariable logistic regressions were performed, adjusting for relevant covariates.

RESULTS

The study encompassed 1014 patients, including 194 patients (19.1%) with discordant umbilical artery pulsatility index values among those who had both umbilical arteries sampled close to delivery, 671 patients (66.2%) with both umbilical arteries having normal pulsatility index values, and 149 patients (14.7%) with both umbilical arteries exhibiting abnormal values. Pregnancies with discordant umbilical artery pulsatility index values displayed compromised sonographic parameters compared with those with both umbilical arteries showing normal pulsatility index values. Similarly, the number of abnormal umbilical artery pulsatility index values was associated with adverse perinatal outcomes in a dose-response manner. Cases with 1 abnormal (discordant) umbilical artery pulsatility index value showed favorable sonographic parameters and perinatal outcomes compared with cases with both abnormal umbilical artery pulsatility index values, and cases with both abnormal umbilical artery pulsatility index values showed worse sonographic parameters and perinatal outcomes compared with cases with discordant UA PI values. Multivariate analysis revealed that discordant umbilical artery pulsatility indices were significantly and independently associated with composite adverse perinatal outcomes, with an adjusted odds ratio of 1.75 (95% confidence interval, 1.24-2.47; P = .002).

CONCLUSION

Evaluating the resistance indices of both umbilical arteries may provide useful data and assist in assessing adverse perinatal outcomes among fetuses with growth restriction.

Plethysmography: A game changer for chronic venous insufficiency diagnosis, treatment, and follow-up

OBJECTIVE

Chronic Venous Insufficiency (CVI) presents a various clinical symptoms and treatment options. Although it is generally known which treatment option is more appropriate in which situations in CVI, it is even more difficult to find the right option in some uncertain situations. In this study, we aimed to evaluate the potential contribution of Digital Photoplethysmography (D-PPG) in the diagnosis of CVI and especially in the selection of treatment options.

PATIENTS AND METHOD

This retrospective study was conducted at Bursa Heart and Arrhythmia Hospital, involving 721 consecutive patients diagnosed with CVI and with Endovenous Laser Ablation (EVLA) indication. The patients were divided into 2 groups according to the extent of the failure in Doppler USG. In Group 1, the insufficiency ended above the knee, and in Group 2, the insufficiency progressed to below the knee. Patients were evaluated based on anamnesis, physical examination, Doppler USG, and D-PPG. Clinical classification, Venous Clinic Severity Score (VCSS), Quality of Life (QoL) assessment, venous pump capacity (VPC), and venous refill time (VRT) were measured.

RESULTS

The study included 263 male and 458 female patients with a mean age of 52.37 ± 12.26 years. Significant differences were observed between Group 1 (above knee reflux) and Group 2 (below knee reflux) patients in terms of VCSS, QoL, VPC, and VRT values. The mean values of VCSS, patient complaints, VPC, and VRT were higher in Group 2 patients. Similar findings were observed within the CEAP 2 subgroup.

CONCLUSION

D-PPG shows potential as a valuable tool in the diagnosis and treatment of CVI. By providing information about venous hemodynamics and volume changes, it can assist in optimizing treatment decisions, including saphenous vein preservation. Combining D-PPG with Doppler USG may improve the comprehensive assessment of CVI and change the treatment option, especially for CEAP 2 patients. More research is needed to confirm these findings and explore wider applications of plethysmographic methods in the management of CVI.

Aortic arch blood flow measurements as a predictor of successful ECMO weaning in cardiogenic shock

Objective

Acute cardiogenic shock is a life-threatening condition with mortality rates of up to 50%. If conventional therapy fails, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) therapy has emerged to a promising alternative for temporary cardiac and respiratory support in specialized centers. However, it is only a bridge to recovery, final decision, heart transplantation or the permanent implantation of a left ventricular assist device. Therefore, the identification of the optimum weaning time point is challenging, and standardized weaning protocols are rare.

Methods

In this explorative pilot study, we evaluated the potential benefit of blood flow measurements in the aortic arch using an ultrasonic cardiac output monitor (USCOM) for the primary endpoint of successful VA-ECMO weaning. 12 patients under VA-ECMO therapy for acute cardiogenic shock and a hemodynamic condition which qualified for a stepwise weaning process were included in this study. Main exclusion criterion was the presence of additional venting therapy for left ventricular unloading, e.g. Impella. Statistical comparisons were performed using the Mann-Whitney test and corrected for multiple testing by the Holm-Sidak method.

Results

Peak velocity of flow in the aortic arch showed a positive correlation with weaning success independent of ECMO flow (weaning success vs. failure: 0.75 vs. 0.35 m/s (low ECMO support), p = 0.049), whereas we identified only a trend for mean pressure gradient, minute distance and stroke volume index.

Conclusion

We hypothesize, that USCOM might provide an additive benefit to conventional strategies in its ability to predict successful VA-ECMO weaning and prevent pulmonary congestion. Larger upcoming trials are required to address this relevant topic and provide standardized treatment protocols for optimized weaning in the future.

Multimodality Imaging in a Patient With Double Aortic Arch Undergoing Transcatheter Aortic Valve Implantation

Double aortic arch is a rare congenital malformation often identified as an incidental finding during routine imaging. In our case, we describe aortic hemodynamics of double aortic arch in a patient with severe aortic stenosis and the procedural process of transcatheter aortic valve implantation.

Prediction of labour outcomes using prelabour computerised cardiotocogram and maternal and fetal Doppler indices: A prospective cohort study

OBJECTIVES

To investigate the association and the potential value of prelabour fetal heart rate short-term variability (STV) determined by computerised cardiotocography (cCTG) and maternal and fetal Doppler in predicting labour outcomes.

DESIGN

Prospective cohort study.

SETTING

The Prince of Wales Hospital, a tertiary maternity unit, in Hong Kong SAR.

POPULATION

Women with a term singleton pregnancy in latent phase of labour or before labour induction were recruited during May 2019-November 2021.

METHODS

Prelabour ultrasonographic assessment of fetal growth, Doppler velocimetry and prelabour cCTG monitoring including Dawes-Redman CTG analysis were registered shortly before induction of labour or during the latent phase of spontaneous labour.

MAIN OUTCOME MEASURES

Umbilical cord arterial pH, emergency delivery due to pathological CTG during labour and neonatal intensive care unit (NICU)/special care baby unit (SCBU) admission.

RESULTS

Of the 470 pregnant women invited to participate in the study, 440 women provided informed consent and a total of 400 participants were included for further analysis. Thirty-four (8.5%) participants underwent emergency delivery for pathological CTG during labour. A total of 6 (1.50%) and 148 (37.00%) newborns required NICU and SCBU admission, respectively. Middle cerebral artery pulsatility index (MCA-PI) and MCA-PI z-score were significantly lower in pregnancies that required emergency delivery for pathological CTG during labour compared with those that did not (1.23 [1.07-1.40] versus 1.40 [1.22-1.64], p = 0.002; and 0.55 ± 1.07 vs. 0.12 ± 1.06), p = 0.049]. This study demonstrated a weakly positive correlation between umbilical cord arterial pH and prelabour log10 STV (r = 0.107, p = 0.035) and the regression analyses revealed that the contributing factors for umbilical cord arterial pH were smoking (p = 0.006) and prelabour log10 STV (p = 0.025).

CONCLUSIONS

In pregnant women admitted in latent phase of labour or for induction of labour at term, prelabour cCTG STV had a weakly positive association with umbilical cord arterial pH but was not predictive of emergency delivery due to pathological CTG during labour.

Acute kidney injury in children undergoing cardiac surgery: predictive value of kidney arterial Doppler-based variables

BACKGROUND

Acute kidney injury (AKI) is a common condition in critically ill children and is associated with increased morbidity and mortality. This study aimed to assess the performance of point-of-care ultrasonography to predict AKI in children undergoing cardiac surgery.

METHODS

In this prospective study, consecutive children underwent kidney Doppler ultrasound examination within 24 h following cardiac surgery, and an experienced operator obtained both renal resistive index (RRI) and renal pulsatility index (RPI). AKI was defined by the Kidney Disease Improving Global Outcome (KDIGO) criteria. The primary outcome was the diagnosis of severe AKI (KDIGO stage 2 or 3) on day 3.

RESULTS

A total of 58 patients were included. Median age and weight were 12.9 months (IQR 6.0-37.9) and 7.36 kg (IQR 5.19-11.40), respectively. On day 3, 13 patients were classified as having AKI, of which 11 were severe. RRI could effectively predict AKI (area under the ROC curve [AUC] 0.83, 95% CI 0.71-0.92; p < 0.001) as well as RPI (AUC 0.81, 95% CI 0.69-0.90; p < 0.001). The optimal cutoff value for RRI was 0.85 (sensitivity, 73%; specificity, 83%; positive predictive value [PPV], 50%; and negative predictive value [NPV], 93%), while for RPI was 1.95 (sensitivity, 73%; specificity, 78%; PPV, 44%; and NPV, 92%). Similar results were found in the analysis for prediction on day 5. Significant correlations were found between Doppler-based variables and estimated GFR and furosemide dose on day 3.

CONCLUSIONS

Kidney Doppler ultrasound may be a promising tool for predicting AKI in children undergoing cardiac surgery.

Ultrasound diagnosis of Mondor's disease involving the superficial scrotal veins: Unveiling a rare mimicker of acute scrotal emergencies

We describe a rare case of Mondor disease of the superficial scrotal veins, which can clinically mimic acute testicular pathologies such as testicular torsion or epididymo-orchitis, and highlight the value of grayscale/Doppler ultrasound examination in distinguishing these entities, which have different management implications.

Effects of sildenafil on Doppler parameters, maternal and neonatal outcomes in the active labor phase of low-risk pregnancies: a randomized clinical trial

OBJECTIVES

The benefits of sildenafil by increasing blood flow in the improvement of Doppler parameters of umbilical (UA), uterine (UtA), and fetal middle cerebral arteries (MCA) remain uncertain. On the other hand, insufficient blood flow during uterine contractions in labor can lead to decrease blood supply and fetal distress. Therefore, we aimed to assess the changes in fetal Doppler indices and maternal and neonatal outcomes following the use of sildenafil in the active phase of labor in low-risk pregnancies with healthy fetuses.

METHODS

This randomized double-blinded controlled trial was conducted on 70 pregnant single low-risk, pregnant women. The patients were randomly assigned into two groups receiving sildenafil (n=35) or placebo (n=35) when the active phase of labor was initiated. Doppler parameters were assessed at baseline as well as 3 h after that. Indeed, the maternal and neonatal outcomes were compared between groups.

RESULTS

The Doppler parameters including the pulsatility index of MCA, UA, and left and right UtA remained unchanged after the administration of sildenafil. Neonatal outcomes including birth weight, PH of the umbilical artery, Apgar score, respiratory distress syndrome, and neonatal intensive care unit admission as well as maternal outcomes such as cesarean section rate and the occurrence of intrapartum/postpartum hemorrhage had no difference between groups.

CONCLUSIONS

The use of sildenafil in the active phase of labor in low-risk pregnancies may not be beneficial in improving Doppler parameters in MCA, umbilical, and uterine arteries and thus may not improve pregnancy outcomes.

Superficial ulnar artery diagnosed by vascular ultrasound: case report

The largest branch of the terminal division of the brachial artery is the ulnar artery, which arises after the cubital fossa. This artery usually has a deep path in the muscles of the anterior forearm and is responsible for vascularization of the superficial and deep musculature on the ulnar side of the forearm and hypothenar area of the hand. We report an anatomical variant diagnosed by Doppler ultrasound in which the ulnar artery had a superficial position in the forearm. Occurrence of a superficial ulnar artery is rare, but it is an important fact for clinicians, surgeons, and nursing professionals.

Correlation between the vascular resistance index and arteriography for assessment of the distal arterial bed in chronic limb threatening ischemia

Background

Patients with chronic limb threatening ischemia (CLTI) of the lower limbs (LL) undergo arteriography for revascularization surgery planning. Doppler ultrasound (DU) is non-invasive and can provide information about the distal arteries through measurement of the resistance index (RI).

Objectives

To correlate the Rutherford Angiographic Classification with the RI for assessment of the distal arterial bed of the LL.

Methods

A cross-sectional study, conducted at a public tertiary hospital with 120 patients with LL CLTI, from September 2019 to April 2022. The RI of arteries that were candidates for revascularization was compared with the images of the same arteries obtained using arteriography, using the Rutherford Angiographic Classification of the distal bed.

Results

A total of 120 LL were assessed in 120 patients with a mean age of 68.6 years. The sample was 50.0% male and 90.0% of the patients in the sample were classified as Rutherford category five. The RI values found for the arteries of the leg exhibited a statistically significant positive correlation with the Rutherford Classification (anterior tibial, p< 0.01; posterior tibial, p = 0.012 fibular, p = 0.034; and dorsalis pedis, p < 0.001).

Conclusions

In this study, RIs for the arteries of the leg measured using Doppler ultrasound exhibited a positive correlation with the Rutherford Classification. This index could be useful for assessment of the distal arterial bed of the lower limbs of patients with chronic limb threatening ischemia.

A comparison of ultrafast and conventional spectral Doppler ultrasound to measure cerebral blood flow velocity during inguinal hernia repair in infants

BACKGROUND

Ultrafast cerebral Doppler ultrasound enables simultaneous quantification and visualization of cerebral blood flow velocity. The aim of this study is to compare the use of conventional and ultrafast spectral Doppler during anesthesia and their potential to show the effect of anesthesiologic procedures on cerebral blood flow velocities, in relation to blood pressure and cerebral oxygenation in infants undergoing inguinal hernia repair.

METHODS

A single-center prospective observational cohort study in infants up to six months of age. We evaluated conventional and ultrafast spectral Doppler cerebral ultrasound measurements in terms of number of successful measurements during the induction of anesthesia, after sevoflurane induction, administration of caudal analgesia, a fluid bolus and emergence of anesthesia. Cerebral blood flow velocity was quantified in pial arteries using conventional spectral Doppler and in the cerebral cortex using ultrafast Doppler by peak systolic velocity, end diastolic velocity and resistivity index.

RESULTS

Twenty infants were included with useable conventional spectral Doppler images in 72/100 measurements and ultrafast Doppler images in 51/100 measurements. Intraoperatively, the success rates were 53/60 (88.3%) and 41/60 (68.3%), respectively. Cerebral blood flow velocity increased after emergence for both conventional (end diastolic velocity, from 2.01 to 2.75 cm/s, p < 0.001) and ultrafast spectral Doppler (end diastolic velocity, from 0.59 to 0.94 cm/s), whereas cerebral oxygenation showed a reverse pattern with a decrease after the emergence of the infant (85% to 68%, p < 0.001).

CONCLUSION

It is possible to quantify cortical blood flow velocity during general anesthesia using conventional and ultrafast spectral Doppler cerebral ultrasound. Cerebral blood flow velocity and blood pressure decreased, while regional cerebral oxygenation increased during general anesthesia. Ultrafast spectral Doppler ultrasound offers novel insights into perfusion within the cerebral cortex, unattainable through conventional spectral ultrasound. Yet, ultrafast Doppler is curtailed by a lower success rate and a more rigorous learning curve compared to conventional method.

A high burden of diabetes and ankle brachial index abnormalities exists in Mexican Americans in South Texas

Ethnic differences exist in the United States in the interrelated problems of diabetes (DM), peripheral arterial disease (PAD), and leg amputations. The purpose of this study was to determine the prevalence and risk factor associations for subclinical PAD in a population sample of Mexican Americans using the ankle brachial (ABI) index. The ABI-High (higher of the two ankle pressures/highest brachial pressure) and ABI-Low (lower of the two ankle pressures/highest brachial pressure) were calculated to define PAD. Toe brachial index (TBI) was also calculated. 746 participants were included with an age of 53.4 ± 0.9 years, 28.3 % had diabetes mellitus (DM), 12.6 % were smokers, and 51.2 % had hypertension (HTN). Using ABI-High ≤ 0.9, the prevalence of PAD was 2.7 %. This rose to 12.7 % when an ABI-Low ≤ 0.9 was used; 4.0 % of the population had an ABI-High > 1.4. The prevalence of TBI < 0.7 was 3.9 %. DM was a significant risk factor for ABI-High ≤ 0.9 and ABI-High > 1.4, and TBI < 0.7. Increased age, HTN, smoking was associated with ABI-High ≤ 0.9, while being male was associated with ABI-High > 1.4. Increased age, smoking, and lower education were all associated with abnormal TBI. Despite relatively younger mean age than other studied Hispanic cohorts, the present population has a high burden of ABI abnormalities. DM was a consistent risk factor for PAD. These abnormalities indicate an important underlying substrate of vascular and metabolic disease that may predispose this population to the development of symptomatic PAD and incident amputations.

The correlation between carotid artery Doppler and stroke volume during central blood volume loss and resuscitation

BACKGROUND

Using peripheral arteries to infer central hemodynamics is common among hemodynamic monitors. Doppler ultrasound of the common carotid artery has been used in this manner with conflicting results. We investigated the relationship between changing common carotid artery Doppler measures and stroke volume (SV), hypothesizing that more consecutively-averaged cardiac cycles would improve SV-carotid Doppler correlation.

METHODS

Twenty-seven healthy volunteers were recruited and studied in a physiology laboratory. Carotid artery Doppler pulse was measured with a wearable, wireless ultrasound during central hypovolemia and resuscitation induced by a stepped lower body negative pressure protocol. The change in maximum velocity time integral (VTI) and corrected flow time of the carotid artery (ccFT) were compared with changing SV using repeated measures correlation.

RESULTS

In total, 73,431 cardiac cycles were compared across 27 subjects. There was a strong linear correlation between changing SV and carotid Doppler measures during simulated hemorrhage (repeated-measures linear correlation [Rrm ]=0.91 for VTI; 0.88 for ccFT). This relationship improved with larger numbers of consecutively-averaged cardiac cycles. For ccFT, beyond four consecutively-averaged cardiac cycles the correlation coefficient remained strong (i.e., Rrm of at least 0.80). For VTI, the correlation coefficient with SV was strong for any number of averaged cardiac cycles. For both ccFT and VTI, Rrm remained stable around 25 consecutively-averaged cardiac cycles.

CONCLUSIONS

There was a strong linear correlation between changing SV and carotid Doppler measures during central blood volume loss. The strength of this relationship was dependent upon the number of consecutively-averaged cardiac cycles.

Application opportunity of Doppler ultrasound combined with CT angiography in diabetic lower extremity arterial disease and the analysis of the risk factors

Objective

This study examined the potential of combining Doppler ultrasound (DUS) and CT angiography (CTA) for early detection and intervention of lower extremity arterial disease (LEAD) in diabetes.Concurrently, risk factors influencing LEAD progression were analyzed.

Methods

106 Type-2 diabetes patients with LEAD, having undergone DUS and CTA, were divided into four stages according to Fontaine stage. Results of DUS and CTA were compared across stages and potential risk factors were analyzed.

Results

Positive detection rates of LEAD differed between DUS and CTA for Fontaine stages I and II (P < 0.05), with no significant difference for stages III and IV (P > 0.05). CTA identified subgroups with mild to moderate stenosis and severe stenosis or occlusion, with positive rates on DUS of 17.95% and 89.9% respectively. Hypertension was found as an independent risk factor affecting LEAD progression.

Conclusion

CTA should be performed early for LEAD in diabetes patients at Fontaine stages I and II, regardless of DUS results. For diabetes patients with LEAD, stringent blood pressure control is crucial to delay disease progression.

Association of low pregnancy associated plasma protein-A with increased umbilical artery pulsatility index in cases of fetal weight between the 3rd and 10th percentiles: a retrospective cohort study

OBJECTIVES

This study aims to evaluate if low levels of serum maternal pregnancy associated plasma protein-A (PAPP-A) during the first trimester are related to increased umbilical artery pulsatility index (UA PI) later in pregnancy, in cases of estimated fetal weight between the 3rd and 10th percentiles, in order to establish PAPP-A as a predictor of this particular cases of fetal growth restriction (FGR).

METHODS

An observational, retrospective cohort study, conducted at a tertiary University Hospital located in Oporto, Portugal. Pregnant women who did the first trimester combined screening, between May 2013 and June 2020 and gave birth in the same hospital, with an estimated fetal weight (EFW) between the 3rd and 10th percentiles were included. The primary outcome is the difference in increased UA PI prevalence between two groups: PAPP-A<0.45 MoM and PAPP-A≥0.45 MoM. As secondary outcomes were evaluated differences in neonatal weight, gestational age at delivery, cesarean delivery, neonatal intensive care unit hospitalization, 5-min Apgar score below 7 and live birth rate between the same two groups.

RESULTS

We included 664 pregnancies: 110 cases of PAPP-A<0.45 MoM and 554 cases with PAPP-A≥0.45 MoM. Increased UA PI prevalence, which was the primary outcome of this study, was significantly different between the two groups (p=0.005), as the PAPP-A<0.45 MoM group presents a higher prevalence (12.7 %) when compared to the PAPP-A≥0.45 MoM group (5.4 %). The secondary outcome cesarean delivery rate was significantly different between the groups (p=0.014), as the PAPP-A<0.45 MoM group presents a higher prevalence (42.7 %) than the PAPP-A≥0.45 MoM group (30.1 %). No other secondary outcomes showed differences between the two groups.

CONCLUSIONS

There is an association of low serum maternal PAPP-A (<0.45 MoM) during the first trimester and increased UA PI (>95th percentile) later in pregnancy, in cases of EFW between the 3rd and 10th percentiles. However, this association is not strong enough alone for low PAPP-A to be a reliable predictor of increased UA PI in this population.

The left ventricular outflow tract and carotid artery velocity time integrals

The left ventricular outflow tract velocity time integral (LVOT VTI) is commonly used in the intensive care unit as a measure of stroke volume (SV) and how the SV changes in response to an intervention; therefore, the LVOT VTI is used to guide intravenous fluid management. Various peripheral Doppler surrogates are proposed to infer the LVOT VTI (e.g., measures from the common carotid artery). A recently-described, novel method of insonation has an excellent ability to detect change in the LVOT VTI. This approach raises important facets of Doppler flow and insonation error, as well as the general principles at play when using a peripheral artery to infer changes from the left ventricle. Relating the VTI of a peripheral artery to the LVOT VTI was recently described mathematically and may help clinicians think about the Doppler relationship between central and peripheral flow.

A Quantitative Method for the Evaluation of Deep Vein Thrombosis in a Murine Model Using Three-Dimensional Ultrasound Imaging

Deep vein thrombosis (DVT) is a life-threatening condition that can lead to its sequelae pulmonary embolism (PE) or post-thrombotic syndrome (PTS). Murine models of DVT are frequently used in early-stage disease research and to assess potential therapies. This creates the need for the reliable and easy quantification of blood clots. In this paper, we present a novel high-frequency 3D ultrasound approach for the quantitative evaluation of the volume of DVT in an in vitro model and an in vivo murine model. The proposed method involves the use of a high-resolution ultrasound acquisition system and semiautomatic segmentation of the clot. The measured 3D volume of blood clots was validated to be correlated with in vitro blood clot weights with an R2 of 0.89. Additionally, the method was confirmed with an R2 of 0.91 in the in vivo mouse model with a cylindrical volume from macroscopic measurement. We anticipate that the proposed method will be useful in pharmacological or therapeutic studies in murine models of DVT.

Noninvasive carotid ultrasound for predicting vulnerable plaques of the coronary artery based on optical coherence tomography images

Background

The risk factors for coronary and carotid plaque development are consistent. Coronary plaque rupture is a major cause of adverse cardiovascular events. Ultrasound can evaluate vulnerable carotid plaques and provide information for predicting vulnerable coronary plaques identified by optical coherence tomography (OCT). This study aimed to investigate the predictive role of non-invasive carotid ultrasound in OCT diagnosis of atherosclerotic vulnerable plaque.

Methods

A total of 70 participants, including 35 patients with and 35 without vulnerable coronary plaque, were enrolled in this case-control study at Beijing Anzhen Hospital from 2016 to 2021. The data of 70 patients with suspected coronary heart disease who had undergone OCT examination during percutaneous coronary intervention (PCI) surgery and completed carotid ultrasound examination within 3 days before PCI were analyzed retrospectively. According to the OCT diagnostic criteria for vulnerable plaques, the patients were divided into the vulnerable-plaque group and the stable-plaque group. Univariate and binary logistic regression analyses assessed risk factors for vulnerable coronary plaque. Receiver operating characteristic (ROC) curve analysis was used to determine the predictive power of carotid plaque features.

Results

The univariate analysis demonstrated that the differences in high-sensitivity C-reactive protein levels and carotid plaque characteristics (irregular fibrous cap, heterogeneous plaque, hypoechoic plaque, plaque calcification, and a plaque thickness of greater than 3 mm) between the two groups were statistically significant. The logistic multivariate regression analysis revealed that an irregular fibrous cap of a carotid plaque [odds ratio (OR) =4.819; 95% confidence interval (CI): 1.106-22.867; P=0.048] and a hypoechoic plaque (OR =9.632; 95% CI: 2.138-43.384; P<0.05) were independent risk factors for predicting vulnerable plaques of the coronary artery.

Conclusions

Noninvasive carotid ultrasound is feasible and clinically valuable for predicting vulnerable and asymptomatic coronary plaques defined by OCT. With this method, adverse events can be diagnosed and treated in advance.

Association of radiocephalic arteriovenous anatomical markers with post-angioplasty blood flow volume

BACKGROUND

Doppler ultrasound (DUS) blood volume flow (VF) calculation is the most reliable method for demonstrating the success of endovascular treatment of dysfunctional radiocephalic arteriovenous fistula (AVF). Due to the difficulty of this method for the interventionalist, VF-correlated markers are required during the procedure.

PURPOSE

To investigate the relationship between intraprocedural anatomical markers (AMs) and changes in VF induced by percutaneous transluminal angioplasty (PTA).

MATERIAL AND METHODS

The study included 56 patients with dysfunctional radiocephalic AVF who underwent PTA between September 2020 and 2022. The VF of all patients was measured using DUS before and 1 h after PTA. AMs were determined from 10 images, five before and five after balloon angioplasty.

RESULTS

The mean post-PTA VF was 637 ± 277 mL/min compared to baseline (151 ± 107 mL/min). Before and after balloon angioplasty, vein diameter (VD), artery diameter (AD), stenosis minimum luminal diameter (MLD), stenosis percentage (SP), and VF values were statistically significant (P = 0.001). Spearman's correlation analysis showed a positive strong linear relationship between VF and MLD (rs = 0.850, P <0.001), and a negative strong linear relationship between VF and SP (rs = 0.815). Receiver operating characteristic curve analysis showed that the sensitivity and specificity for VF ≥400 mL/min at cutoffs of SP <50% and MLD >2.5 mm were 81% and 82%, and 81% and 90%, respectively.

CONCLUSION

Among the AMs readily available during PTA, first MLD and then SP provided satisfactory results in predicting VF.

Follow-up study of isolated calf muscular vein thrombosis for anticoagulant therapy after primary hip and knee arthroplasty

BACKGROUND

Although isolated calf muscular vein thrombosis (ICMVT) is commonly seen after hip and knee arthroplasty, no treatment guidelines for ICMVT after joint replacement are available. The purpose of this study was to evaluate the outcomes of patients with ICMVT for anticoagulant therapy at different time points after primary hip and knee arthroplasty.

METHODS

Patients with ICMVT after primary hip and knee arthroplasty were included in the study. Diagnosis was established with Doppler ultrasound. Patients were followed up clinically and with Doppler ultrasound at 1, 2, and 3 months. The outcomes were efficacy (complete resolution) and acceptability (hemorrhagic events). Anticoagulant therapy at curative dosage was prescribed for 1 month and was extended for 2 additional months in case of incomplete resolution at 1 month or if propagation was present. The chi-square test was used to compare the outcomes at different time points.

RESULTS

302 patients were taken hip and knee arthroplasty from January 2021 to May 2022, in which 51 patients presented with 51 ICMVTs postoperatively. The incidence of ICMVT was about 16.89%. Resolution of ICMVT was considered complete at 1, 2, and 3 months at 36.73%, 61.22%, and 91.84%, respectively, with significant differences among the time points (P < 0.05). All patients with ICMVT receiving anticoagulant therapy remained free of propagations and hemorrhagic events within 3 months.

CONCLUSION

Our findings provide new insights into the anticoagulant therapy for ICMVT after primary hip and knee arthroplasty, taking oral Rivaroxaban for 3 months is effective and safe, which contributes to provide the reference for clinical practice.

Perfusion Changes in Acute Septic Arthritis of the Hip Joint During Infancy Using Doppler USG

Objectives

To quantitatively assess vascularity changes of acute septic hips in infants using Doppler ultrasonography. To compare these findings with asymptomatic hips, and establish a correlation for accurate diagnosis between these findings.

Methods

In this prospective case-control study, we included all children under 1 year of age with a diagnosis of acute septic arthritis of the hip in the case group. For the control group, we enrolled apparently healthy, full-term neonates and infants not affected with any hip pathology. Doppler ultrasound of the medial femoral circumflex artery of the hip joint was done using a single Phillips HDI 5000 sonography machine. Following parameters were studied: peak systolic velocity (PSV), resistive index (RI), pulsatility index (PI), and systolic to diastolic ratio (SD ratio).

Results

Doppler signals and spectral waveforms were obtainable in 100% of hips in both groups. A statistically significant difference was found between the cases and controls with respect to their PSVs, RIs, PIs and SD ratios. The most striking difference was found between the PSVs of the two groups, whose mean was 6.18 in the control group and 11.8 in the case group. No significant correlation between age/gender and any of the 4 parameters was found.

Conclusion

Doppler parameters are useful in raising suspicion of onset in the diagnosis of septic arthritis. No correlation was found between age or gender and any parameter in control group. These baseline values can be held valid for all children below the age of 7 months.

[Functional transcranial dopplerography is a diagnostic tool for cognitive impairment syndrome]

Functional transcranial dopplerography (FTCD) is a non-invasive ultrasound examination that allows recording the dynamics of cerebral blood flow parameters under conditions of factors stimulated the activity of the structures of the central nervous system. Judgments about the sensitivity and specificity of FTCD are based on the close connection between changes in the activity of the nervous (somatic) system and the response of regional cerebral blood flow (CBF). The technique is a portable and accessible diagnostic method used in assessing the possibility of expanding functional activity during the recovery period after a stroke. An increase in mental activity in response to the presentation of a cognitive task, accompanied by an increase in glucose and oxygen consumption and naturally requiring an increase in cerebral perfusion parameters, can also be assessed by changes in regional blood flow parameters while maintaining the reactive mechanisms of autoregulation. A search of literature sources was carried out in the electronic databases PubMed and Scopus. For the subject search, Medical Subject Headings were used. A total of 36 sources that mentioned the terms «cognitive function» and «functional transcranial Doppler» were selected for preliminary analysis. At the present stage, methodological problems are obvious, requiring the development and implementation of a standard package of targeted functional tests to assess cognitive status. Available equipment and software require technological solutions to ensure objective recording of changes in cerebral blood flow during testing and training.

A Robust Approach Assisted by Signal Quality Assessment for Fetal Heart Rate Estimation from Doppler Ultrasound Signal

Fetal heart rate (FHR) monitoring, typically using Doppler ultrasound (DUS) signals, is an important technique for assessing fetal health. In this work, we develop a robust DUS-based FHR estimation approach complemented by DUS signal quality assessment (SQA) based on unsupervised representation learning in response to the drawbacks of previous DUS-based FHR estimation and DUS SQA methods. We improve the existing FHR estimation algorithm based on the autocorrelation function (ACF), which is the most widely used method for estimating FHR from DUS signals. Short-time Fourier transform (STFT) serves as a signal pre-processing technique that allows the extraction of both temporal and spectral information. In addition, we utilize double ACF calculations, employing the first one to determine an appropriate window size and the second one to estimate the FHR within changing windows. This approach enhances the robustness and adaptability of the algorithm. Furthermore, we tackle the challenge of low-quality signals impacting FHR estimation by introducing a DUS SQA method based on unsupervised representation learning. We employ a variational autoencoder (VAE) to train representations of pre-processed fetal DUS data and aggregate them into a signal quality index (SQI) using a self-organizing map (SOM). By incorporating the SQI and Kalman filter (KF), we refine the estimated FHRs, minimizing errors in the estimation process. Experimental results demonstrate that our proposed approach outperforms conventional methods in terms of accuracy and robustness.

The combined use of ultrasound examination of hemodynamics in the umbilical artery and urine microalbumin levels can predict adverse pregnancy outcomes in patients with severe preeclampsia

The aim of this study was to elucidate the application of ultrasound examination of umbilical artery (UA) hemodynamics with urine microalbumin (UmA) determination in evaluating the outcomes of sPE patients. Altogether 80 sPE patients and 75 healthy pregnant women were recruited. UmA, RI (resistance index) and PI (pulsatility index) were separately measured by ELISA and the ultrasonic Doppler flow detector. The correlation between parameters was analysed using Pearson's coefficient method. The independent risk factors of sPE were identified using the Logistic regression model. sPE patients had increased UmA, RI and PI (all p < 0.05). UmA level was positively correlated with RI and PI in sPE patients. RI, PI and UmA were independent risk factors of sPE (all p < 0.05). sPE can predict adverse pregnancy outcomes. High UmA levels may increase the risk of poor prognosis. Overall, ultrasound examination of UA hemodynamics with UmA determination can predict the adverse pregnancy outcomes of sPE patients.IMPACT STATEMENTWhat is already known on this subject? Doppler ultrasound and urine microalbumin (UmA) measurement are important tools in assessing the clinical severity of severe preeclampsia (sPE).What do the results of this study add? This study aims to unravel the application of ultrasound examination of hemodynamics in the umbilical artery (UA) combined with the determination of UmA in evaluating the outcomes of sPE patients.What are the implications of these findings for clinical practice and/or further research? Ultrasound examination of hemodynamics in UA combined with the determination of UmA can predict the adverse pregnancy outcomes of sPE patients.

Diastolic deceleration area in the fetal MCA: a new Doppler parameter

Objective: Doppler velocimetry has been widely used throughout the years as a valuable tool in the follow-up and prognosis of various pregnancy complications. Numerous Doppler indices have been introduced to qualitatively describe fetal blood flow. Currently, the Pulsatility index (PI) is the most widely used index for this purpose. In current clinical practice, middle cerebral artery (MCA) PI measurement is commonly used to assess fetal well-being, especially in late-onset fetal growth restriction (FGR). However, existing evidence suggests that MCA PI alone is inferior to the ratio between MCA and umbilical artery (UA) pulsatility indices in predicting adverse perinatal and neonatal outcomes. When comparing normal and abnormal MCA Doppler waveforms, it is evident that most changes appear in the diastolic part of the heart cycle. Therefore, the PI, which contains elements from both systole (peak systolic velocity-PSV) and diastole (end-diastolic velocity), may not be the most effective tool for quantifying fetal brain sparing (BS).Methods: We hypothesize that another measurement modality that focuses predominantly on the diastole could be more efficient for evaluating the amount of vasodilatation. In ultrasound velocimetry of larger blood vessels, there is a well-known phenomenon called "dicrotic notch" (DN), which appears on the declining part of each Doppler waveform and can be used to precisely pinpoint the end of systole and the start of diastole. We hypothesized that the extent of cerebral vasodilation can be more accurately assessed by measuring the area between the dicrotic notch (DN) and the end-diastolic velocity (which we refer to as the "diastolic deceleration area-DDA"). In this study, we introduced a new Doppler parameter along with a rationale for DDA measurement in the fetal MCA. We also defined third-trimester nomograms and provided a preliminary assessment of the correlation between DDA and fetal oxygen deficiency.Results: Our findings suggest that the DDA may serve as an independent instrument for identifying hypoxia during late pregnancy, either on its own or in conjunction with other Doppler and cardiotocography modalities.Conclusion: However, before incorporating DDA into clinical practice, it is crucial to conduct further research and validation studies with larger sample sizes and more diverse populations. This would help assess the generalizability of the results and establish optimal cutoff points for DDA in various clinical settings. It is also important to prospectively study the role of DDA in early- and late-onset fetal growth restriction (FGR), Rh-isoimmunization/anemia, preeclampsia, gestational diabetes, and other pregnancy complications. In fact, we believe that the concept of measuring specific areas in arterial Doppler velocimetry indices could have significant implications not only in fetal medicine and obstetrics, but also in other areas of human and veterinary medicine.

Comparison of the carotid corrected flow time and tidal volume challenge for assessing fluid responsiveness in robot-assisted laparoscopic surgery

We aimed to compare the ability of carotid corrected flow time assessed by ultrasound and the changes in dynamic preload indices induced by tidal volume challenge predicting fluid responsiveness in patients undergoing robot-assisted laparoscopic gynecological surgery in the modified head-down lithotomy position. This prospective single-center study included patients undergoing robot-assisted laparoscopic surgery in the modified head-down lithotomy position. Carotid Doppler parameters and hemodynamic data, including corrected flow time, pulse pressure variation, stroke volume variation, and stroke volume index at a tidal volume of 6 mL/kg predicted body weight and after increasing the tidal volume to 8 mL/kg predicted body weight (tidal volume challenge), respectively, were measured. Fluid responsiveness was defined as a stroke volume index ≥ 10% increase after volume expansion. Among the 52 patients included, 26 were classified as fluid responders and 26 as non-responders based on the stroke volume index. The area under the receiver operating characteristic curve measured to predict the fluid responsiveness to corrected flow time and changes in pulse pressure variation (ΔPPV6-8) after tidal volume challenge were 0.82 [95% confidence interval (CI) 0.71-0.94; P < 0.0001] and 0.85 (95% CI 0.74-0.96; P < 0.0001), respectively. The value for pulse pressure variation at a tidal volume of 8 mL/kg was 0.79 (95% CI 0.67-0.91; P = 0.0003). The optimal cut-off values for corrected flow time and ΔPPV6-8 were 357 ms and > 1%, respectively. Both the corrected flow time and Changes in pulse pressure variation after tidal volume challenge reliably predicted fluid responsiveness in patients undergoing robot-assisted laparoscopic gynecological surgery in the modified head-down lithotomy position. And pulse pressure variation at a tidal volume of 8 mL/kg maybe also a useful predictor.Trial registration: Chinese Clinical Trial Register (CHiCTR2200060573, Principal investigator: Hongliang Liu, Date of registration: 05/06/2022).

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

OBJECTIVES

To assess whether there is an association between abnormal common femoral vein (CFV) Doppler waveform and intensive care unit (ICU) mortality in patients with sepsis.

METHODS

Patients admitted to the ICU with sepsis were included. Pulsed-wave Doppler was performed by examining the CFV in the short axis without angle correction and in the long axis with angle correction. An abnormal CFV Doppler waveform was determined by a retrograde velocity peak (RVP) > 10 cm/s in the long axis or RVP > 50% of the antegrade velocity peak in the short axis. TAPSE < 17 mm was defined as right ventricular (RV) dysfunction. The primary outcome was ICU mortality.

RESULTS

One hundred and ten patients were included. There was no association between abnormal CFV Doppler waveforms in the long (p = 0.709) and short axes (p = 0.171) and ICU mortality. TAPSE measurements were performed in 16 patients. RV dysfunction was identified in 8 (50.0%) patients. There was no association between the diagnosis of RV dysfunction based on TAPSE measurement and the identification of abnormal CFV Doppler waveforms in the long axis (p = 1.000) and in the short axis (p = 1.000).

CONCLUSION

Abnormal CFV Doppler waveforms were not associated with ICU mortality in patients with sepsis. Furthermore, in the exploratory analysis, these alterations were not useful in identifying RV dysfunction in these patients.

Reduction in peripheral arterial stiffness after reactive hyperemia is dependent on increases in blood flow

The acute reduction in peripheral arterial stiffness during reactive hyperemia is assumed to be flow-mediated; however, the mechanism remains unproven. We hypothesized that restricting the blood flow increase during reactive hyperemia would abolish the reduction in peripheral arterial stiffness. Fourteen healthy young adults (5 females, 25 ± 5 years, mean ± SD) underwent reactive hyperemia with a rapid-release cuff on the upper arm inflated to 220 mmHg for 5 min: once with unrestricted blood flow and once with restricted blood flow by manually applying pressure to the brachial artery. Brachial-radial pulse wave velocity (PWV) was measured with tonometers over brachial and radial arteries before cuff inflation and at 5, 15, and 30 min after release. Brachial blood flow was monitored with Doppler ultrasound. Baseline brachial-radial PWV was similar between conditions (10.3 ± 1.8 vs. 10.7 ± 1.7 m/s). With unrestricted flow, PWV decreased 5 min post-reactive hyperemia (8.6 ± 1.1 m/s; p < 0.05) and returned near baseline at 15 and 30 min post (p < 0.05). With restricted flow, PWV did not change (p > 0.05) post-reactive hyperemia. Reactive hyperemia acutely reduced peripheral arterial stiffness, but not when brachial artery blood flow increase was restricted. This suggests that the reduction in peripheral arterial stiffness during reactive hyperemia depends on increased blood flow.

Association of umbilical vein flow with abnormal fetal growth and adverse perinatal outcome in low-risk population: multicenter prospective study

OBJECTIVES

To investigate the relationship of umbilical vein flow (UVF) measured close to term with abnormal fetal growth and adverse perinatal outcome in a cohort of pregnancies at low risk of placental insufficiency.

METHODS

This was a prospective multicenter observational study conducted across two tertiary maternity units. Patients with a singleton appropriate-for-gestational-age fetus between 35 and 38 weeks' gestation were included. Pregnancies at higher risk of placental insufficiency or with fetal anomalies were excluded. At ultrasound examination, the abdominal circumference (AC), umbilical vein diameter and peak velocity of the umbilical vein were measured, and, using these variables, a new variable, UVF/AC, was calculated. The primary outcome was the occurrence of severely stunted fetal growth, defined as a greater than 40-percentile drop between estimated fetal weight at the third-trimester ultrasound and birth weight between the third-trimester ultrasound and delivery. The occurrence of adverse perinatal outcome, defined as one of the following: neonatal acidosis (umbilical artery pH < 7.15 and/or base excess > 12 mmol/L) at birth, 5-min Apgar score < 7, neonatal resuscitation or neonatal intensive care unit admission, was analyzed as a secondary outcome.

RESULTS

Between April 2021 and March 2023, 365 women were included in the study. The mean UVF/AC at enrolment was 6.4 ± 2.6 mL/min/cm, and 35 (9.6%) cases were affected by severely stunted fetal growth. Severely stunted fetal growth was associated with a lower mean UVF/AC (5.4 ± 2.6 vs 6.5 ± 2.6 mL/min/cm; P = 0.02) and a higher frequency of UVF/AC < 10th percentile (8/35 (22.9%) vs 28/330 (8.5%); P = 0.01). Moreover, UVF/AC showed an area under the receiver-operating-characteristics curve (AUC) of 0.65 (95% CI, 0.55-0.75; P = 0.004) in predicting the occurrence of severely stunted fetal growth, and the optimal cut-off value of UVF/AC for discriminating between normal and severely stunted fetal growth was 7.2 mL/min/cm. This value was associated with a sensitivity and specificity of 0.77 (95% CI, 0.60-0.90) and 0.33 (95% CI, 0.28-0.39), and positive and negative predictive values of 0.11 (95% CI, 0.07-0.15) and 0.93 (95% CI, 0.87-0.97), respectively. Regarding the occurrence of adverse perinatal outcome, this was associated independently with maternal age (adjusted odds ratio (aOR), 0.93 (95% CI, 0.87-0.99); P = 0.04), UVF/AC Z-score (aOR, 0.53 (95% CI, 0.30-0.87); P = 0.01) and augmentation of labor (aOR, 2.69 (95% CI, 1.28-5.69); P = 0.009). UVF/AC showed an AUC of 0.65 (95% CI, 0.56-0.73; P = 0.005) in predicting the occurrence of adverse perinatal outcome, and the optimal cut-off value of UVF/AC for discriminating between normal and adverse perinatal outcome was 6.7 mL/min/cm. This value was associated with a sensitivity and specificity of 0.70 (95% CI, 0.54-0.83) and 0.40 (95% CI, 0.34-0.45), and positive and negative predictive values of 0.14 (95% CI, 0.09-0.19) and 0.91 (95% CI, 0.85-0.95), respectively.

CONCLUSIONS

Our data demonstrate an association between reduced UVF close to term, severely stunted fetal growth and adverse perinatal outcome in a cohort of low-risk pregnant women, with a moderate ability to rule out and a poor ability to rule in either outcome. Further studies are needed to establish whether the assessment of UVF can improve the identification of fetuses at risk of subclinical placental insufficiency and adverse perinatal outcome. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Respiratory variation in the internal jugular vein does not predict fluid responsiveness in the prone position during adolescent idiopathic scoliosis surgery: a prospective cohort study

BACKGROUND

Respiratory variation in the internal jugular vein (IJVV) has not shown promising results in predicting volume responsiveness in ventilated patients with low tidal volume (Vt) in prone position. We aimed to determine whether the baseline respiratory variation in the IJVV value measured by ultrasound might predict fluid responsiveness in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion (PSF) with low Vt.

METHODS

According to the fluid responsiveness results, the included patients were divided into two groups: those who responded to volume expansion, denoted the responder group, and those who did not respond, denoted the non-responder group. The primary outcome was determination of the value of baseline IJVV in predicting fluid responsiveness (≥15% increases in stroke volume index (SVI) after 7 ml·kg-1 colloid administration) in patients with AIS undergoing PSF during low Vt ventilation. Secondary outcomes were estimation of the diagnostic performance of pulse pressure variation (PPV), stroke volume variation (SVV), and the combination of IJVV and PPV in predicting fluid responsiveness in this surgical setting. The ability of each parameter to predict fluid responsiveness was assessed using a receiver operating characteristic curve.

RESULTS

Fifty-six patients were included, 36 (64.29%) of whom were deemed fluid responsive. No significant difference in baseline IJVV was found between responders and non-responders (25.89% vs. 23.66%, p = 0.73), and no correlation was detected between baseline IJVV and the increase in SVI after volume expansion (r = 0.14, p = 0.40). A baseline IJVV greater than 32.00%, SVV greater than 14.30%, PPV greater than 11.00%, and a combination of IJVV and PPV greater than 64.00% had utility in identifying fluid responsiveness, with a sensitivity of 33.33%, 77.78%, 55.56%, and 55.56%, respectively, and a specificity of 80.00%, 50.00%, 65.00%, and 65.00%, respectively. The area under the receiver operating characteristic curve for the baseline values of IJVV, SVV, PPV, and the combination of IJVV and PPV was 0.52 (95% CI, 0.38-0.65, p=0.83), 0.54 (95% CI, 0.40-0.67, p=0.67), 0.58 (95% CI, 0.45-0.71, p=0.31), and 0.57 (95% CI, 0.43-0.71, p=0.37), respectively.

CONCLUSIONS

Ultrasonic-derived IJVV lacked accuracy in predicting fluid responsiveness in patients with AIS undergoing PSF during low Vt ventilation. In addition, the baseline values of PPV, SVV, and the combination of IJVV and PPV did not predict fluid responsiveness in this surgical setting.

TRAIL REGISTRATION

This trial was registered at www.chictr.org (ChiCTR2200064947) on 24/10/2022. All data were collected through chart review.

Comparison of Doppler ultrasound indices of uterine artery and sub endometrial blood supply in frozen embryo transfer with and without repeated implantation failure: A cross-sectional study

Background: Uterine blood supply has been identified as a potential factor in implantation failure. Objective: This study aimed to investigate Doppler indices in the uterine artery, including vascular flow and resistance, as well as the amount of sub-endometrial blood supply in women with a history of repeated implantation failure (RIF) compared to the non-RIF group. Materials and Methods: This cross-sectional study was conducted with 139 women candidates for frozen embryo transfer in Yazd Reproductive Sciences Institute, Yazd, Iran from February to July 2023. Group A (n = 68) included women with a history of more than 2 RIF, and group B (n = 71) included women candidates for implantation for the first time without RIF. Doppler ultrasound indices of uterine artery and sub-endometrium, including sub-endometrial flow, uterine artery flow, uterine artery resistance, and peak systolic velocity, were recorded. Results: No significant differences were observed in uterine artery Doppler pulsatility index and peak systolic velocity between groups, but the uterine artery resistance index was significantly higher in the A group (p < 0.001). A significant difference was observed in the perfusion area between groups. 60/68 women in the group A had endometrial perfusion in areas 2 and 3 (p < 0.001). Conclusion: Our study revealed that women with RIF exhibited higher resistance index in sub-endometrial arteries compared to the non-RIF group.

Role of colour Doppler in predicting foetal outcome in maternal anaemia

Context

Anaemia is the most common nutritional deficiency in Indian pregnant females. It ensues foetal hypoxia resulting in different compensatory mechanisms in the foetus which may result in adverse perinatal outcomes. Colour Doppler can be used to measure these hemodynamic changes of the foetus ahead of the clinical manifestations, guiding the obstetrician for the appropriate management and circumventing any dire complication.

Aims

The aim of this study is to detect foetal haemodynamic changes associated with maternal anaemia and assess the parameters which predict these changes accurately.

Settings and Design

Prospective cohort study.

Materials and Methods

Two hundred and forty pregnant females in the third trimester, divided into four groups based on their haemoglobin levels in the non-anaemic, mild, moderate and severe anaemic groups, were included in the study. These patients were followed up for foetal outcome in terms of effective foetal weight, APGAR score and neonatal intensive care unit admission.

Statistical Analysis Used

Analysis of Variance Appearance, Pulse, Grimace, Activity and Respiration (ANOVA) test was used to compare the quantitative variables. SPSS software was used.

Results

The middle cerebral artery (MCA) Doppler indices and cerebroplacental ratio (CPR) values were increasing while umbilical Doppler indices were decreasing with the increasing severity of anaemia. CPR was found to be the most sensitive predictor for foetal outcome.

Conclusions

Maternal anaemia results in foetal hypoxia which can be measured in terms of foetal Doppler indices. CPR was found to be more sensitive than the umbilical or MCA in predicting foetal hypoxia and in turn the perinatal outcome of foetuses of anaemic pregnant females. The foetuses with low CPR values will require urgent intervention to improve the outcomes.

First experiences of ultrasound vector flow imaging at the femoropopliteal artery in peripheral arterial disease

Background: The femoropopliteal artery (FPA) plays a central role in diagnosing and treating peripheral arterial disease (PAD). FPA lesions are the most frequent cause of intermittent claudication, and no other artery of the lower extremities is recanalised more frequently. Generally, ultrasound is the primary imaging tool in PAD, particularly FPA. With the development of high-frame-rate ultrasound technology in addition to traditional ultrasound modes, vector flow imaging (VFI) has provided deeper haemodynamic insights when used in the carotid artery. Here, we report the use of VFI at the FPA level in routine PAD examinations. Patients and methods: In this single-centre prospective study, we evaluated consecutive patients with PAD using B-mode imaging, colour Doppler, pulsed wave Doppler (PW) and vector flow. Hemodynamic parameters at predefined locations at the carotid artery and FPA were compared. Results: Qualitatively adequate VFI at all sites was possible in 76% of the patients with PAD. With decreasing volume flow from the common carotid artery to the internal carotid artery and from the common femoral artery via the superficial femoral artery to the popliteal artery, the correlation between VFI- and PW-derived-volume flow was high at every site. Based on different techniques, the VFI-derived values were significantly lower than the PW-derived values. The mean wall shear stress was significantly lower at all femoropopliteal sites than at the carotid sites, whereas the oscillatory shear index at the femoral site was higher than that at the carotid sites rather than at the popliteal location. Conclusions: Our findings suggest that vector flow data acquisition in the FPA is feasible in most patients with PAD. Therefore, with knowledge of the method and its limitations, VFI provides haemodynamic information beyond traditional ultrasound techniques and is a promising new tool for flow analysis in PAD.

Shunt rate of ductus arteriosus and ductus venosus in middle and late fetuses and their application value in the evaluation of fetal growth restriction

Objective

To explore the Shunt rate of ductus arteriosus (DA) and ductus venosus (DV) in middle and late fetuses and their application value in the evaluation of fetal growth restriction (FGR).

Methods

In this retrospective observational study, we reviewed the clinical data of the patients who admitted to the Second Affiliated Hospital of Wenzhou Medical University from September 10, 2017 to November 27, 2018, and finally included 44 normal women at 28-31 weeks of pregnancy (Normal group) and 15 pregnant women with fetal growth restriction (FGR) within 28-31 weeks of gestation (FGR group). We measured blood flows of the DA (QDA), pulmonary artery (QPA), DV (QDV), and umbilical vein (QUV) and the shunt rates of the DA and DV (QDA/QPA and QDV/QUV, respectively) in all fetuses. We compared the mean variables between groups using the Normal group means as the normal reference values for analysis.

Results

DA shunt rate was linearly and positively correlated with gestational age (Y=1.455X+2.787; r=0.767, P<0.01), while the DV shunt rate was linearly and negatively correlated with gestational age (Y=-2.791X+126.885; r=0.761, P<0.01). The DA shunt rates (QDA/QPA) of fetuses in the normal were higher than those in the FGR groups, but the differences between the two groups were not statistically significant (P > 0.05). The DV shunt rates (QDV/QUV) of fetuses in the normal were significantly lower than those in the FGR groups (P < 0.05). The DV shunt rates in the FGR group were significantly higher than those in the normal group with differences being statistically significant at 30-30+6 and 31-31+6 gestational weeks (P < 0.05) The receiver operating characteristic curve (ROC curve) showed that the higher the shunt rate, the worse the birth outcome of a fetus with FGR.

Conclusions

The DV shunt rate in middle- and late-stage fetuses can predict the fetal birth outcome, and the higher the shunt ratio, the worse the birth outcome of FGR fetuses.

Three-dimensional mapping of the greater palatine artery location and physiology

OBJECTIVE

To develop a novel technique for localizing and reconstructing the greater palatine artery (GPA) using three-dimensional (3D) technology.

METHODS

A miniaturized intraoral ultrasound transducer was used to imaging landmarks including the GPA, gingival margin (GM), and palatal masticatory mucosa (PMM). A 5-mm-thick solid hydrogel couplant was integrated to replace traditional ultrasound gel and avoid bubbles when moving the transducer.

RESULTS

A panorama image provided the relative localization of landmarks including the GPA, PMM, and hard palate. Short- and long-axis imaging of GPA was performed in five subjects including 3D mapping of GPA branches and surrounding tissues in a volume of 10 mm × 8 mm × 10 mm. Full-mouth Doppler imaging was also demonstrated on both the dorsal and ventral tongue as well as buccal mucosa and sublingual region on two subjects.

CONCLUSIONS

This study can measure the vertical distance from the GM to the GPA and depth from PMM to GPA and visualize the GPA localization in a 3D manner, which is critical to evaluate the available volume of palatal donor tissues and avoid sectioning of GPA during surgical harvesting of the tissues. Finally, the transducer's small size facilitates full-mouth Doppler imaging with the potential to improve the assessment, diagnosis, and management of oral mucosa.

Differential average daily gain of pregnant Holstein × Gyr dairy heifers causes placental adaptations to support fetal growth and development

This study aimed to evaluate the effects of differential average daily gain targets of dairy heifers throughout gestation on placental hemodynamics, uterine involution, colostrum production of the heifers, and effects on newborn calf weight and immunity transfer. Fourteen Holstein × Gyr heifers with an average body weight of 446 ± 46.7 kg and age of 25 ± 3.9 mo were randomly assigned to the following treatments: moderate body weight gain (MOD, n = 7), where heifers were fed to achieve 0.50 kg/d; and high body weight gain (HIG, n = 7), where heifers were fed to achieve 0.75 kg/d. Target average daily gains were established based on common tropical dairy production systems. The heifers received a total mixed ration feed twice daily starting at 70 d of gestation. Placentome vascularization was assessed using a color Doppler ultrasound at 180, 210, and 240 d of gestation. After calving, cotyledons were counted and sampled to analyze the mRNA expression of placental angiogenesis markers. After birth, calves were weighed and fed colostrum, and transfer of passive immunity efficiency was assessed. A significant increase in cotyledons was detected for MOD placenta soon after expulsion (81.5 ± 12.91 vs. 63.6 ± 10.52). Placentome vascularization at the final third of gestation increased for MOD heifers compared with HIG. Greater mRNA expression after membrane expulsion of VEGFB and IGFR1 in cotyledons and a greater estradiol concentration in circulation 1 d before calving was found for MOD heifers compared with HIG heifers; however, uterine involution postpartum was not different between treatment groups. Greater colostrum production was observed in HIG heifers (3.9 ± 1.05 vs. 2.2 ± 1.57 L) but with lower quality (25.2 ± 0.51 vs. 29.5 ± 0.65 Brix). No differences were observed in birth weight or transfer of passive immunity efficiency between treatments; however, HIG calves had significantly greater vitality scores than MOD calves. The results of this study indicate that a moderate feeding regimen enhances placental blood flow by increasing angiogenesis, which suggests improved nutrient transfer to the fetus without major effects on its development during the neonatal stage, colostrum production, or uterine involution in the heifers.

The Correlation between Carotid Artery Corrected Flow Time and Velocity Time Integral during Central Blood Volume Loss and Resuscitation

Background

Doppler ultrasound of the common carotid artery is used to infer central hemodynamics. For example, change in the common carotid artery corrected flow time (ccFT) and velocity time integral (VTI) are proposed surrogates of changing stroke volume. However, conflicting data exist which may be due to inadequate beat sample size and measurement variability - both intrinsic to handheld systems. In this brief communication, we determined the correlation between changing ccFT and carotid VTI during progressively severe central blood volume loss and resuscitation.

Methods

Measurements were obtained through a novel, wireless, wearable Doppler ultrasound system. Sixteen participants (ages of 18-40 years with no previous medical history) were studied across 25 lower body-negative pressure protocols. Relationships were assessed using repeated-measures correlation regression models.

Results

In total, 33,110 cardiac cycles comprise this analysis; repeated-measures correlation showed a strong, linear relationship between ccFT and VTI. The strength of the ccFT-VTI relationship was dependent on the number of consecutively averaged cardiac cycles (R1 cycle = 0.70, R2 cycles = 0.74, and R10 cycles = 0.81).

Conclusions

These results positively support future clinical investigations employing common carotid artery Doppler as a surrogate for central hemodynamics.

Risk of adverse perinatal outcomes in pregnancies with "small" fetuses not meeting Delphi consensus criteria for fetal growth restriction

BACKGROUND

Previous research endeavors examining the association between clinical characteristics, sonographic indices, and the risk of adverse perinatal outcomes in pregnancies complicated by fetal growth restriction have been hampered by a lack of agreement regarding its definition. In 2016, a consensus definition was reached by an international panel of experts via the Delphi procedure, but as it currently stands, this has not been endorsed by all professional organizations.

OBJECTIVE

This study aimed to assess whether an independent association exists between estimated fetal weight and/or abdominal circumference of <10th percentile and adverse perinatal outcomes when consensus criteria for growth restriction are not met.

STUDY DESIGN

Data were derived from a passive prospective cohort of singleton nonanomalous pregnancies at a single academic tertiary care institution (2010-2022) that fell into 3 groups: (1) consecutive fetuses that met the Delphi criteria for fetal growth restriction, (2) small-for-gestational-age fetuses that failed to meet the consensus criteria, and (3) fetuses with birthweights of 20th to 80th percentile randomly selected as an appropriately grown (appropriate-for-gestational-age) comparator group. This nested case-control study used 1:1 propensity score matching to adjust for confounders among the 3 groups: fetal growth restriction cases, small-for-gestational-age cases, and controls. Our primary outcome was a composite: perinatal demise, 5-minute Apgar score of <7, cord pH of ≤7.10, or base excess of ≥12. Pregnancy characteristics with a P value of <.2 on univariate analyses were considered for incorporation into a multivariable model along with fetal growth restriction and small-for-gestational-age to evaluate which outcomes were independently predictive of adverse perinatal outcomes.

RESULTS

Overall, 2866 pregnancies met the inclusion criteria. After propensity score matching, there were 2186 matched pairs, including 511 (23%), 1093 (50%), and 582 (27%) patients in the small-for-gestational-age, appropriate-for-gestational-age, and fetal growth restriction groups, respectively. Moreover, 210 pregnancies (10%) were complicated by adverse perinatal outcomes. None of the pregnancies with small-for-gestational-age OR appropriate-for-gestational-age fetuses resulted in perinatal demise. Twenty-three of 511 patients (5%) in the small-for-gestational-age group had adverse outcomes based on 5-minute Apgar scores and/or cord gas results compared with 77 of 1093 patients (7%) in the appropriate-for-gestational-age group (odds ratio, 0.62; 95% confidence interval, 0.39-1.00). Furthermore, 110 of 582 patients (19%) with fetal growth restriction that met the consensus criteria had adverse outcomes (odds ratio, 3.08; 95% confidence interval, 2.25-4.20), including 34 patients with perinatal demise or death before discharge. Factors independently associated with increased odds of adverse outcomes included chronic hypertension, hypertensive disorders of pregnancy, and early-onset fetal growth restriction. Small-for-gestational age was not associated with the primary outcome after adjustment for 6 other factors included in a model predicting adverse perinatal outcomes. The bias-corrected bootstrapped area under the receiver operating characteristic curve for the model was 0.72 (95% confidence interval, 0.66-0.74). The bias-corrected bootstrapped area under the receiver operating characteristic curve for a 7-factor model predicting adverse perinatal outcomes was 0.72 (95% confidence interval, 0.66-0.74).

CONCLUSION

This study found no evidence that fetuses with an estimated fetal weight and/or abdominal circumference of 3rd to 9th percentile that fail to meet the consensus criteria for fetal growth restriction (based on Doppler waveforms and/or growth velocity of ≥32 weeks) are at increased risk of adverse outcomes. Although the growth of these fetuses should be monitored closely to rule out evolving growth restriction, most cases are healthy constitutionally small fetuses. The management of these fetuses in the same manner as those with suspected pathologic growth restriction may result in unnecessary antenatal testing and increase the risk of iatrogenic complications resulting from preterm or early term delivery of small fetuses that are at relatively low risk of adverse perinatal outcomes.

Transient ischemic attack due to dynamic evolution of carotid artery web

Carotid artery web (CaW) is a rare focal fibromuscular dysplasia, which is an underappreciated risk factor for transient ischemic attack. This case illustrates the dynamic evolution of secondary thrombus and plaque in CaW, and the importance of carotid doppler ultrasound in early detection and follow-up.