A prospective study of super-thin anterolateral thigh flap harvesting assisted by high-frequency color Doppler ultrasound in detecting perforators in deep adipose layers / 中国修复重建外科杂志

OBJECTIVE@#To investigate the clinical application of high-frequency color Doppler ultrasound (HFCDU) in detecting perforators in the deep adipose layers for harvesting super-thin anterolateral thigh flap (ALTF).@*METHODS@#Between August 2019 and January 2023, 45 patients (46 sides) with skin and soft tissue defects in the foot and ankle were treated, including 29 males and 16 females, aged from 22 to 62 years, with an average of 46.7 years. The body mass index ranged from 19.6 to 36.2 kg/m 2, with an average of 23.62 kg/m 2. The causes of injury included traffic accident injury in 15 cases, heavy object crush injury in 20 cases, mechanical injury in 8 cases, heat crush injury in 1 case, and chronic infection in 1 case. There were 20 cases on the left side, 24 cases on the right side, and 1 case on both sides. After thorough debridement, the wound size ranged from 5 cm×4 cm to 17 cm×11 cm. All patients underwent free super-thin ALTF transplantation repair. HFCDU was used to detect the location of the perforators piercing the deep and superficial fascia, as well as the direction and branches of the perforators within the deep adipose layers before operation. According to the preoperative HFCDU findings, the dimensions of the super-thin ALTF ranged from 6 cm×4 cm to 18 cm×12 cm. The donor sites of the flaps were directly sutured.@*RESULTS@#A total of 55 perforators were detected by HFCDU before operation, but 1 was not found during operation. During operation, a total of 56 perforators were found, and 2 perforators were not detected by HFCDU. The positive predictive value of HFCDU for identifying perforator vessels was 98.2%, and the sensitivity was 96.4%. Among the 54 perforators accurately located by HFCDU, the orientation of the perforators in the deep adipose layers was confirmed during operation. There were 21 perforators (38.9%) traveled laterally and inferiorly, 12 (22.2%) traveled medially and inferiorly, 14 (25.9%) traveled laterally and superiorly, 5 (9.3%) traveled medially and superiorly, and 2 (3.7%) ran almost vertically to the body surface. Among the 54 perforators accurately located by HFCDU, 35 were identified as type 1 perforators and 12 as type 2 perforators (HFCDU misidentified 7 type 2 perforators as type 1 perforators). The sensitivity of HFCDU in identifying type 1 perforators was 100%, with a positive predictive value of 83.3%. For type 2 perforators, the sensitivity was 63.2%, and the positive predictive value was 100%. The surgeries were successfully completed. The super-thin ALTF had a thickness ranging from 2 to 6 mm, with an average of 3.56 mm. All super-thin ALTF survived, however, 1 flap experienced a venous crisis at 1 day after operation, but it survived after emergency exploration and re-anastomosis of the veins; 1 flap developed venous crisis at 3 days after operation but survived after bleeding with several small incisions; 3 flaps had necrosis at the distal edge of the epidermis, which healed after undergoing dressing changes. All 45 patients were followed up 6-18 months (mean, 13.6 months). Three flaps required secondary defatting procedures, while the rest had the appropriate thickness, and the overall appearance was satisfactory.@*CONCLUSION@#Preoperative application of HFCDU to detect the perforator in the deep adipose layers can improve the success and safety of the procedure by facilitating the harvest of super-thin ALTF.

Correlation of uterine artery Doppler flow velocimetry and β-human chorionic gonadotropin levels during postmolar evacuation surveillance: A pilot study in a tertiary hospital / Philippine Journal of Obstetrics and Gynecology

Background@#During postmolar evacuation surveillance, beta-human chorionic gonadotropin (β-hCG) regression levels can predict invasive disease while Doppler ultrasound can assess in vivo tumor neovascularization and quantify uterine blood supply. As an ancillary tool to β-hCG monitoring, ultrasound can detect the early presence of viable trophoblastic tissues and identify patients at risk of developing postmolar gestational trophoblastic Neoplasia (PMGTN). @*Objective@#The objective of this study was to correlate uterine artery Doppler ultrasound with β-hCG levels during pre- and postmolar evacuation surveillance among patients with complete mole.@*Materials and Methods@#A cohort of patients with sonographic diagnosis of complete hydatidiform mole and managed with suction curettage in the same institution were prospectively followed up after evacuation. The pre- and postmolar evacuation surveillance period was at days 1, 7, 14, 21, 28, and 35. Monitoring of serum β-hCG levels was based on the standard regression curve. For Doppler ultrasound parameters, monitoring of the systolic/diastolic (S/D) ratio, pulsatility index (PI), resistance index (RI), and peak systolic velocity (PSV) was based on its relationship with its serum β-hCG levels. The ultrasound images generated were archived and reviewed by the authors. Descriptive and inferential statistics were utilized to analyze median differences. For the correlation of uterine artery Doppler flow parameters, analysis for the test of difference used Pearson correlation and multiple linear regression analysis for the odds ratio.@*Results@#Sixteen of the 23 enrolled patients completed the protocol (16 of 23, 69.50%). A majority had spontaneous remission (13; 81%) while 3 cases (19%) presented increasing and plateauing β-hCG levels. The pre- and post evacuation median β-hCG levels showed a significant decrease (P = 0.001). As post evacuation β-hCG levels decreased, PSV also decreased (r = 0.478, P = 0.061) while Doppler parameters, RI, PI, and S/D ratio increased. However, when post evacuation β-hCG levels rose or plateaued, Doppler parameters decreased. These changes had statistical correlation (all P < 0.05). Moreover, the magnitude of the relationship for β-hCG and Doppler parameters was moderate and ranged from 0.524 to 0.581. Among the Doppler parameters, the S/D ratio and RI of the right uterine artery strongly predicted a rise in β-hCG levels. The odds ratio of predicting increased β-hCG levels and risk of gestational trophoblastic neoplasia by the right S/D ratio were − 2683.67 (confidence interval [CI] = −271.692–5095.655; P = 0.034) and by the right RI − 66,193.34 (CI = −161,818.107–29,431.433; P = 0.046). Notably, Doppler parameter changes appeared early at day 14 up to day 35 and before the appearance of abnormal β-hCG regression patterns.@*Conclusion@#There is a strong correlation between uterine artery Doppler flow changes and β-hCG levels during postmolar evacuation surveillance. The inverse relationship of the S/D ratio, PI and RI, and β-hCG regression patterns confirms spontaneous remission of the disease. For patients with abnormal β-hCG patterns, this relationship is altered. The Doppler changes become erratic, unpredictable, and significantly decreased. These changes were detected as early as 2 weeks post evacuation. Thus, the use of ultrasound as an adjunct to β-hCG post evacuation surveillance can predict abnormal β-hCG regression patterns and identify patients at risk of developing postmolar gestational trophoblastic neoplasia (PMGTN).

Relação entre o índice de resistência vascular e o sucesso hemodinâmico de revascularizações distais dos membros inferiores / Vascular resistance index and the immediate hemodynamic success of lower limb distal artery revascularization

Resumo Contexto A cirurgia de revascularização é proposta para restaurar o fluxo sanguíneo para o pé nos casos de isquemia crítica (IC) devido a doença arterial obstrutiva periférica dos membros inferiores (MMII). O uso de ultrassonografia com Doppler (USD) vem despontando nos últimos anos como um método de grande valor para o planejamento cirúrgico dessa intervenção. Objetivos Avaliar a relação entre o índice de resistência (IR), mensurado por meio de USD, e o sucesso hemodinâmico imediato da cirurgia de revascularização dos MMII em pacientes com IC. Métodos O tipo de estudo empregado foi a coorte prospectiva, na qual foram avaliados 46 pacientes portadores de IC dos MMII submetidos à operação de revascularização infrainguinal por angioplastia ou em ponte de agosto de 2019 a fevereiro de 2022. Todos os pacientes foram submetidos à avaliação clínica vascular, à USD com medida do IR das artérias distais dos MMII, à arteriografia dos MMII e à aferição do índice tornozelo-braquial (ITB) no período pré-operatório. No pós-operatório imediato, todos os pacientes foram submetidos à nova aferição do ITB. Resultados Entre os 46 pacientes avaliados, 25 (54,3%) eram do sexo masculino. A idade variou de 32 a 89 anos (média de 67,83). Quanto ao sucesso hemodinâmico, avaliado pela comparação do ITB pré e pós-operatório, constatou-se que 31 (67,4%) pacientes apresentaram sucesso hemodinâmico após cirurgia de revascularização (aumento do ITB em 0,15 ou mais). Foi observada correlação positiva (p ≤ 0,05) entre o IR da artéria distal revascularizada do MMII e o sucesso hemodinâmico imediato avaliado pela aferição do ITB (IR menor e sucesso hemodinâmico). Conclusões Na presente pesquisa foi observada uma correlação positiva entre o índice de resistência arterial distal e o sucesso hemodinâmico nas revascularizações dos membros inferiores, avaliada através do índice tornozelobraquial, de forma que, quanto menor foi o IR, maior o sucesso hemodinâmico obtido.

Abstract Background Revascularization surgery is used to attempt to restore blood flow to the foot in patients with critical ischemia (CI) caused by peripheral arterial occlusive disease of the lower limbs (LL). Ultrasonography with Doppler (USD) SAH emerged in recent years as a highly valuable method for planning this surgical intervention. Objectives To evaluate the relationship between the resistance index (RI), measured with USD, and immediate hemodynamic success of LL revascularization surgery in patients with CI. Methods The study design was a prospective cohort assessing 46 patients with LL CLI who underwent operations to perform infrainguinal revascularization by angioplasty or bypass from August 2019 to February 2022. All patients underwent preoperative clinical vascular assessment with USD including measurement of the RI of distal LL arteries, LL arteriography, and measurement of the ankle-brachial index (ABI). All patients had their ABI measured again in the immediate postoperative period. Results Forty-six patients were assessed, 25 (54.3%) of whom were male. Age varied from 32 to 89 years (mean: 67.83). Hemodynamic success was assessed by comparison of preoperative and postoperative ABI, showing that hemodynamic success was achieved in 31 (67.4%) patients after revascularization surgery (ABI increased by 0.15 or more). A positive correlation (p ≤ 0.05) was observed between the RI of the distal revascularized LL artery and immediate hemodynamic success assessed by ABI (lower RI and hemodynamic success). Conclusions This study observed a positive correlation between the resistance index of the distal artery and immediate hemodynamic success of lower limb revascularizations, as assessed by the ankle-brachial index, so that the lower the RI the greater the hemodynamic success achieved.

Artéria ulnar superficial diagnosticada por ultrassom vascular: relato de caso / Superficial ulnar artery diagnosed by vascular ultrasound: case report

Resumo O maior ramo da divisão terminal da artéria braquial é a artéria ulnar, que se origina após a fossa cubital. Essa artéria usualmente tem trajeto profundo aos músculos do antebraço anterior e é responsável pela vascularização da musculatura superficial e profunda da região ulnar do antebraço e hipotênar da mão, sendo a principal responsável pela formação do arco palmar superficial após o retináculo dos flexores. Reportamos uma variação anatômica após diagnóstico com ultrassom vascular na qual a artéria ulnar situava-se em posição superficial no antebraço. A ocorrência da artéria ulnar superficial é rara, porém de grande importância para clínicos, cirurgiões e profissionais de enfermagem.

Abstract 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.

Correlação entre o índice de resistência vascular e a arteriografia na avaliação do leito arterial distal na isquemia crítica dos membros inferiores / Correlation between the vascular resistance index and arteriography for assessment of the distal arterial bed in chronic limb threatening ischemia

Resumo Contexto Pacientes com isquemia crítica (IC) dos membros inferiores (MMII) precisam de arteriografia para o planejamento da cirurgia de revascularização. A ultrassonografia Doppler (UD) não é invasiva e, através da aferição do índice de resistência (IR), pode fornecer informações sobre as artérias distais. Objetivos Correlacionar a Classificação Angiográfica de Rutherford com o IR na avaliação do leito arterial distal dos MMII. Métodos Estudo transversal, realizado em hospital público terciário, com 120 pacientes portadores de IC dos MMII, entre setembro de 2019 a abril de 2022. Foi comparado o IR das artérias da perna passíveis de serem receptoras de revascularização com a imagem obtida através da arteriografia dessas artérias em acordo com a Classificação Angiográfica de leito distal de Rutherford. Resultados Foram avaliados 120 MMII em 120 pacientes com idade média de 68,6 anos. A amostra foi composta de 50,0% de pacientes do sexo masculino. Na amostra, 90,0% pacientes encontravam-se na classe cinco de Rutherford. Os valores do IR encontrados para as artérias de perna apresentaram uma correlação positiva, estatisticamente significativa, quando comparados com a Classificação de Rutherford (tibial anterior, p< 0,01; tibial posterior, p = 0,012 e fibular, p = 0,034 e artéria dorsal do pé, p < 0,001). Conclusões Neste estudo, os IRs das artérias da perna obtidos através da ultrassonografia Doppler apresentaram uma correlação positiva quando comparados à classificação de Rutherford. Em pacientes com isquemia crítica, esse índice pode ser útil na avaliação do leito arterial distal dos membros inferiores.

Abstract 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.

Effects of permanent placental injury due to severe acute respiratory syndrome coronavirus 2 infection during pregnancy on the feto-placental circulation: a cross-sectional study

SUMMARY OBJECTIVE: The aim of this study was to evaluate the effects of permanent placental injury due to a severe acute respiratory syndrome coronavirus 2 infection during pregnancy on feto-placental circulation. METHODS: In this cross-sectional study, 83 pregnant women with planned deliveries were divided into two groups according to their severe acute respiratory syndrome coronavirus 2 infection statuses during pregnancy. Their demographic parameters, obstetric histories, and prenatal risks were evaluated. A prenatal fetal Doppler ultrasound examination was performed for all participants, and umbilical artery and middle cerebral artery Doppler parameters were obtained. Postpartum placentas were examined for pathological findings under appropriate conditions. All placentas were evaluated according to the Amsterdam consensus criteria. Mann-Whitney U test, Student's t-test, and chi-square test were used for comparisons. RESULTS: Demographic parameters were statistically similar, except that they were borderline significant for gestational weeks at delivery (p=0.044). In the pathological examination of the placenta, regardless of the trimester of exposure to viral infection, perivillous fibrin deposition and villus dystrophic calcification were more common in group 2 (p=0.016 and p=0.048, respectively) than in group 1. In the prenatal Doppler examination between the groups, no statistically significant difference was found for all of the umbilical artery pulsatile index, middle cerebral artery pulsatile index, and cerebro-placental ratio values. CONCLUSION: Severe acute respiratory syndrome coronavirus 2 infection during pregnancy causes an increase in perivillous fibrin deposition and villus dystrophic calcification in the placenta. Placental injury caused by the severe acute respiratory syndrome coronavirus 2 virus does not affect fetal Doppler parameters.

Avaliação das alterações anatômicas da bifurcação da artéria braquial através do eco-Doppler vascular: um estudo transversal / Assessment of anatomic variations of the brachial artery bifurcation using vascular Doppler ultrasound: a cross-sectional study

Resumo Contexto Variações anatômicas em artérias do membro superior, como a presença da artéria braquial acessória, são comuns e amplamente descritas na literatura, principalmente por estudos em cadáveres. No entanto, atualmente, é possível realizar o diagnóstico através do eco-Doppler vascular. Objetivos Identificar a incidência da artéria braquial acessória pelo eco-Doppler e comparar os achados com estudos cadavéricos. Métodos Tratou-se de um estudo prospectivo em 500 membros superiores de 250 voluntários avaliados pelo eco-Doppler com o aparelho portátil de ultrassom Sonosite Titan. Resultados Dos participantes do nosso estudo, 15,6% apresentaram a variação anatômica da artéria braquial acessória. A porcentagem está dentro da média encontrada em estudos cadavéricos, que varia de 0,2 até 22%. Ter conhecimento dessa variação é fundamental em procedimentos como punção venosa periférica, fístula arteriovenosa, cateterismo, retalhos de antebraço, cirurgias de emergência no membro superior e até mesmo correção de fraturas por gesso. Conclusões A artéria braquial acessória é uma variante frequente no membro superior. O percentual de indivíduos com a artéria braquial acessória em nosso estudo foi de 15,6% e coincide com os dados da literatura de estudos cadavéricos.

Abstract 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.

Effects of antenatal corticosteroids on fetal hemodynamics: a longitudinal study / Efeitos do corticoide antenatal na hemodinâmica fetal: um estudo longitudinal

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

Resumo Objetivo: Estudar o efeito da administração antenatal de corticosteroides na hemodinâmica fetal mediante análise longitudinal do Doppler na artéria umbilical e artéria cerebral média (ACM). Materiais e Métodos: Este foi um estudo retrospectivo que incluiu 30 fetos com risco de nascimento pré-termo. Vinte e oito gestantes foram tratadas com betametasona para maturação pulmonar fetal. Os exames de Doppler da AU e da ACM foram realizados uma vez antes e depois da administração de corticosteroides, num total de três ou oito observações. Utilizamos o modelo linear hierárquico com abordagem Bayesiana. Foram construídos os intervalos de referência e testadas associações entre variáveis (idade gestacional e pré-eclâmpsia). Resultados: A média ± desvio-padrão da idade materna, idade gestacional na administração de betametasona e idade gestacional no parto foram 32,6 ± 5,89 anos, 30,2 ± 2,59 semanas e 32,9 ± 3,42 semanas, respectivamente. No Doppler da AU, verificou-se diminuição significativa do índice de pulsatilidade (IP) com a terapêutica com corticosteroides (média: 0,1147 [0,03687-0,191]; em três observações) (mediana: 0,1437 [0,02509-0,2627]; em oito observações). No entanto, não foi observada alteração significativa no IP do Doppler da ACM, independentemente da idade gestacional e do diagnóstico de pré-eclâmpsia. Conclusão: Os corticosteroides pré-natais induziram diminuição significativa no IP do Doppler da AU, mas não houve alteração na vasculatura cerebral.

Accuracy of duplex ultrasonography versus angiotomography for the diagnosis of extracranial internal carotid stenosis / Acurácia da ultrassonografia duplex comparada à angiotomografia para o diagnóstico de estenose de carótida interna extracraniana

ABSTRACT Introduction: Internal carotid artery (ICA) stenosis causes about 15% of ischemic strokes. Duplex ultrasonography (DUS) is the first line of investigation of ICA stenosis, but its accuracy varies in the literature and it is usual to complement the study with another more accurate exam when faced with significant stenosis. There is a lack of studies that compare DUS with angiotomography (CTA) in the present literature. Methods: we performed an accuracy study, which compared DUS to CTA of patients in a tertiary hospital with a maximum interval of three months between tests. Patients were selected retrospectively, and two independent and certified vascular surgeons evaluated each image in a masked manner. When there was discordance, a third evaluator was summoned. We evaluated the diagnostic accuracy of ICA stenosis of 50-94% and 70-94%. Results: we included 45 patients and 84 arteries after inclusion and exclusion criteria applied. For the 50-94% stenosis range, DUS accuracy was 69%, sensitivity 89%, and specificity 63%. For the 70-94% stenosis range, DUS accuracy was 84%, sensitivity 61%, and specificity 93%. There was discordance between CTA evaluators with a change from clinical to surgical management in at least 37.5% of the conflicting reports. Conclusion: DUS had an accuracy of 69% for stenoses of 50-94% and 84% for stenoses of 70-94% of the ICA. The CTA analysis depended directly on the evaluator with a change in clinical conduct in more than 37% of cases.

RESUMO Introdução: a estenose da artéria carótida interna (ACI) causa cerca de 15% dos acidentes vasculares cerebrais isquêmicos. A ultrassonografia duplex (USD) é a primeira linha de investigação da estenose de ACI, mas sua acurácia varia na literatura e é comum complementar o estudo com outro exame de maior acurácia diante de estenose significativa. Há uma escassez de estudos que comparem a USD com a angiotomografia computadorizada (ATC) na literatura atual. Métodos: realizamos um estudo de acurácia, que comparou a USD à ATC de pacientes de um hospital terciário com um intervalo máximo de três meses entre os exames. Os pacientes foram selecionados retrospectivamente e dois cirurgiões vasculares independentes e certificados avaliaram cada imagem de maneira mascarada. Quando houve discordância, um terceiro avaliador foi convocado. Avaliou-se a precisão diagnóstica da estenose da ACI de 50-94% e 70-94%. Resultados: foram incluídos 45 pacientes e 84 artérias após a aplicação dos critérios de inclusão e exclusão. Para a faixa de estenose de 50-94%, a acurácia da USD foi 69%, sensibilidade 89% e especificidade 63%. Para a faixa de estenose de 70-94%, a acurácia da USD foi 84%, sensibilidade 61% e especificidade 93%. Ocorreu discordância entre avaliadores da ATC com mudança de conduta clínica para cirúrgica em pelo menos 37,5% dos laudos conflitantes. Conclusão: a USD teve uma acurácia de 69% para estenoses de 50-94% e de 84% para estenoses de 70-94% da ACI. A análise das ATC dependeu diretamente do avaliador com mudança de conduta clínica em mais de 37% dos casos.

Correlation of pelvic ultrasonography with pubertal development in girls

Abstract Objectives: This study aims to correlate pelvic ultrasound with female puberty and evaluate the usual ultrasound parameters as diagnostic tests for the onset of puberty and, in particular, a less studied parameter: the Doppler evaluation of the uterine arteries. Methods: Cross-sectional study with girls aged from one to less than eighteen years old, with normal pubertal development, who underwent pelvic ultrasound examination from November 2020 to December 2021. The presence of thelarche was the clinical criterion to distinguish pubescent from non-pubescent girls. The sonographic parameters were evaluated using the ROC curve and the cutoff point defined through the Youden index (J). Results: 60 girls were included in the study. Uterine volume ≥ 2.45mL had a sensitivity of 93%, specificity of 90%, PPV of 90%, NPV of 93% and accuracy of 91% (AUC 0.972) for predicting the onset of puberty. Mean ovarian volume ≥ 1.48mL had a sensitivity of 96%, specificity of 90%, PPV of 90%, NPV of 97% and accuracy of 93% (AUC 0.966). Mean PI ≤ 2.75 had 100% sensitivity, 48% specificity, 62% PPV, 100% NPV and 72% accuracy (AUC 0.756) for predicting the onset of puberty. Conclusion: Pelvic ultrasound proved to be an excellent tool for female pubertal assessment and uterine and ovarian volume, the best ultrasound parameters for detecting the onset of puberty. The PI of the uterine arteries, in this study, although useful in the pubertal evaluation, showed lower accuracy in relation to the uterine and ovarian volume.

Estudo sobre a prevalência de doença carotídea detectada por ultrassonografia nos casos de AVC isquêmico de um hospital público de Santa Catarina / Study on the prevalence of carotid artery disease detected by ultrasonography in cases of ischemic stroke at a public hospital in Santa Catarina

Fundamento: Acidentes Vasculares Cerebrais Isquêmicos (AVCi) representam significativa parcela dentre as causas da morbimortalidade mundial. Estenose das artérias carótidas e vertebrais são consideradas fator de risco para tal desfecho. A Ultrassonografia com Doppler (USG Doppler) das artérias extracranianas pode ser útil na identificação de pacientes com estenose significativa por ser um método inócuo e acessível. Objetivos: avaliar a prevalência de estenose nas artérias extracranianas diagnosticadas através do estudo com USG Doppler e a prevalência de fatores associados em pacientes com quadro de AVCi. Métodos: Trata-se de estudo retrospectivo, transversal, a partir da análise de prontuários dos pacientes internados com quadro de AVCi no Hospital Regional de São José, Santa Catarina, Brasil. O estudo ocorreu entre janeiro de 2020 e dezembro de 2021. A análise ultrassonográfica foi realizada por médicos radiologistas habilitados, a partir do uso de aparelho validado (GE Logic P9 com transdutor linear multifrequencial 6-15MHz). Resultados: Dentre os 239 pacientes incluídos, destaca-se a significativa prevalência de comorbidades associadas ao AVCi, como hipertensão arterial sistêmica (78,2%) e tabagismo (40,6%). A distribuição entre os sexos foi homogênea (58,2 versus 41,8%) e 70,3% dos pacientes possuíam idade superior a 60 anos de idade. A taxa de pacientes com alterações hemodinamicamente significativas (estenose >50% da luz do vaso) das artérias carótidas e vertebrais foi de 29,2%. O tabagismo foi o único fator de risco que se correlacionou estatisticamente com a ocorrência de AVCi decorrente do acometimento das artérias carótidas ou vertebrais (RP 1,708; IC 1,057-2,761; p=0,028). Conclusão: O USG com Doppler das artérias extracranianas é ferramenta útil na investigação dos casos de AVCi, visto que a prevalência de doença significativa dos grandes vasos extracranianos (estenose>50%) se aproxima de 30%.

Background: Ischemic Strokes represent a sizable portion among the causes of morbidity and mortality worldwide. Stenosis of the carotid and vertebral arteries represent a risk factor to this outcome. Ultrasonography with Doppler of the extracranial arteries can be useful in identifying patients with significant stenosis because it is a harmless and accessible method. Objectives: To assess the prevalence of stenosis in the extracranial arteries diagnosed through Doppler ultrasound examination and the prevalence of associated factors in patients with ischemic stroke Methods: This is a retrospective, cross-sectional study based on the analysis of medical records of patients admitted with ischemic stroke at the Regional Hospital of São José, Santa Catarina, Brazil. The study was conducted between January 2020 and December 2021. Ultrasonographic analysis was performed by qualified radiologists, using a validated device (GE Logic P9 with a multi-frequency linear transducer 6-15MHz). Results: Among the 239 included patients, there is a significant prevalence of comorbidities associated with ischemic stroke, such as systemic arterial hypertension (78.2%) and smoking (40.6%). The distribution between genders was homogeneous (58.2% versus 41.8%), and 70.3% of the patients were over 60 years old. The rate of patients with hemodynamically significant alterations (stenosis >50% of the vessel lumen) in the carotid and vertebral arteries was 29.2%. Smoking was the only risk factor that statistically correlated with the occurrence of ischemic stroke resulting from the involvement of the carotid or vertebral arteries (PR 1.708; CI 1.057-2.761; p=0.028). Conclusion: Ultrasonography with Doppler of the extracranial arteries is a useful tool in the investigation of ischemic stroke cases, given that the prevalence of significant disease in the large extracranial vessels (stenosis >50%) approaches 30%.

Hallazgos por ecografía Doppler arterial oftálmica en pacientes con enfermedad renal crónica avanzada / Ophthalmic Arterial Doppler Ultrasound Findings in Patients with Advanced Chronic Kidney Disease

Objetivo: Determinar los hallazgos por ecografía Doppler arterial oftálmica en pacientes con enfermedad renal crónica avanzada. Métodos: Se efectuó un estudio observacional descriptivo y transversal con 212 órbitas de 106 pacientes con enfermedad renal crónica avanzada (estadios 4 y 5 en tratamiento dialítico). Por interrogatorio y examen físico se identificaron los factores de riesgo aterosclerótico. Además, se realizó ultrasonido orbitario y Doppler carotídeo, y solo en caso de resultar normales, se procedió a evaluar mediante ecografía Doppler las arterias oftálmicas. Resultados: Predominaron los pacientes mayores de 50 años, el sexo masculino, el color mestizo de piel y los normopesos; mientras que la hipertensión arterial, el tabaquismo y la diabetes mellitus tipo 2 fueron los factores de riesgo aterosclerótico mayoritarios. En todos los enfermos renales crónicos se demostró un incremento de la velocidad del flujo y de la resistencia vascular a nivel de las arterias oftálmicas, en tanto los casos con hipertensión arterial y diabetes mellitus tipo 2, así como los hipertensos exclusivos, mostraron los valores hemodinámicos más elevados. Conclusiones: La evaluación de las arterias oftálmicas mediante ecografía Doppler permite hacer un estudio y seguimiento más integral de los pacientes con enfermedad renal crónica avanzada(AU)

Objective: To determine ophthalmic arterial Doppler ultrasound findings in patients with advanced chronic kidney disease. Methods: A descriptive and cross-sectional observational study was carried out with 212 orbits of 106 patients with advanced chronic kidney disease (stages 4 and 5 in dialysis treatment). Atherosclerotic risk factors were identified by interrogation and physical examination. In addition, orbital ultrasound and carotid Doppler were performed, and only if they were normal, the ophthalmic arteries were evaluated by Doppler ultrasound. Results: Patients older than 50 years, male sex, mestizo skin color and normal weight predominated, while arterial hypertension, smoking and type 2 diabetes mellitus were the main atherosclerotic risk factors. An increase in flow velocity and vascular resistance at the level of the ophthalmic arteries was demonstrated in all chronic renal patients, while cases with arterial hypertension and type 2 diabetes mellitus, as well as exclusive hypertensives, showed the highest hemodynamic values. Conclusions: The evaluation of the ophthalmic arteries by Doppler ultrasound allows a more comprehensive study and follow-up of patients with advanced chronic kidney disease(AU)

Diagnóstico prenatal de vasa previa tipo 3, comunicación de un caso

La vasa previa es una patología poco frecuente en la que los vasos umbilicales se encuentran transcurriendo en las cercanías del orificio cervical interno. Habitualmente está asociada a inserción velamentosa del cordón, placenta succenturiata, inserción baja placentaria y fertilización in vitro. Tiene importantes implicancias perinatales el lograr un diagnóstico precoz en el segundo trimestre, porque se logra disminuir la mortalidad neonatal. Presentamos el primer caso de diagnóstico prenatal de vasa previa tipo 3 (una variante poco conocida) comunicado en el Perú en una gestante con placenta previa y sin diagnóstico hasta el tercer trimestre.

Vasa previa is a rare condition in which the umbilical vessels are found to run in the vicinity of the internal cervical os. It is usually associated with velamentous insertion of the umbilical cord, placenta succenturiata, low placenta insertion and in vitro fertilization. Early diagnosis in the second trimester has important perinatal implications because it reduces neonatal mortality. We present the first case of prenatal diagnosis of vasa previa type 3 (a little known variant) reported in Peru in a pregnant woman with placenta previa and undiagnosed until the third trimester.

Endarterectomía carotídea en paciente con estenosis aórtica crítica. Importancia de la anestesia regional y del neuromonitoreo / Carotid endarterectomy in a patient with critical aortic stenosis. Importance of regional anesthesia and transoperative neurological monitoring

Resumen: La estenosis carotídea (EC) ocurre en 13% de los pacientes con estenosis valvular aórtica (EVA). El riesgo de evento vascular cerebral (EVC), en los pacientes con EC significativa sometidos a cirugía valvular cardíaca, puede aumentar hasta 11%. Someter a un paciente con EVA crítica y fracción de eyección del ventrículo izquierdo (FEVI) disminuida a endarterectomía carotídea es todo un reto anestésico, cuyo principal objetivo es evitar la hipotensión y el bajo gasto cardíaco. La anestesia regional es una opción para estos pacientes. Presentamos el caso de un hombre de 70 años con diagnóstico de EC significativa y EVA crítica con disfunción ventricular izquierda, al que se realizó endarterectomía carotídea con bloqueo del plexo cervical superficial por alto riesgo de colapso circulatorio. Dicha estrategia anestésica permitió mantener al paciente despierto durante la cirugía, al valorar continuamente su estado neurológico. Asimismo, se documentaron los cambios transoperatorios en el NIRS (Near-infrared spectroscopy) cerebral y Doppler transcraneal (DTC), los cuales se correlacionaron con el estado clínico del paciente. En un segundo tiempo se hizo cambio valvular aórtico sin complicaciones. En este caso destaca la importancia de la anestesia regional y el monitoreo neurológico con Doppler transcraneal, en pacientes sometidos a endarterectomía carotídea con alto riesgo quirúrgico por EVA crítica.

Abstract: Carotid stenosis occurs in 13% of patients with aortic valve stenosis. The risk of stroke in patients with significant carotid stenosis undergoing heart valve surgery may increase to 11%. Proposing a patient with critical aortic valve stenosis and left ventricular dysfunction to carotid endarterectomy is an anesthetic challenge, where the objective is to avoid hypotension and low cardiac output. Regional anesthesia is an option for these patients. Due to the high incidence of intraoperative stroke during carotid endarterectomy, continuous neurological monitoring is of relevance. We present the case of a 70-year-old man diagnosed with significant carotid stenosis and critical aortic valve stenosis and left ventricular dysfunction who underwent carotid endarterectomy with superficial cervical plexus block due to a high risk of circulatory collapse. In addition, this anesthetic strategy made it possible to keep the patient awake during surgery, and to continuously assess their neurological status. Likewise, transoperative changes in brain NIRS and transcranial Doppler were documented, which correlated with the patient's clinical status. In a second time, aortic valve replacement was performed without complications. This case highlights the importance of regional anesthesia and neurological monitoring in patients undergoing carotid endarterectomy with high surgical risk due to critical aortic valve stenosis.

Manejo del Síndrome de Klippel-Trenaunay: reporte de caso / Management of Klippel-Trenaunay Syndrome: case report / Manejo da Síndrome de Klippel-Trenaunay: relato de caso

El Síndrome de Klippel-Trenaunay se constituye en una malformación vascular compleja con una incidencia de 2 a 3 casos por cada 100.000 nacidos vivos, clínicamente presenta una triada clásica: manchas cutáneas en vino de Oporto, venas varicosas de localización atípica e hipertrofia ósea y de tejidos blandos. Se presenta el caso de una paciente femenina de 33 años, sin antecedentes patológicos o quirúrgicos de importancia quien acude a consulta por aumento de volumen de la extremidad derecha, mancha violácea ipsilateral, además de dolor y parestesias. Al examen físico se evidencia aumento longitudinal de miembro inferior derecho, nevus hiperpigmentario en cara lateral de pierna derecha y muslo que se extiende al glúteo ipsilateral además de venas varicosas atípicas. Se practica ecografía Doppler venosa con transductor lineal que reporta incompetencia de vena Safena Mayor y perforantes suprageniculares. Se realizó manejo quirúrgico mediante safenectomía, corrección de deformidad y referencia a dermatología para terapia láser por el nevus hiperpigmentario. La paciente mostró evolución clínico - quirúrgica favorable con remisión de la sintomatología que motivó su consulta.

Klippel-Trenaunay syndrome is a complex vascular malformation with an incidence of 2 to 3 cases per 100,000 live births. Clinically, it presents a classic triad: port-wine stains, varicose veins of atypical location and bone and soft tissue hypertrophy. We present the case of a 33-year-old female patient, with no pathologic or surgical history of importance, who comes to the clinic for an increase in volume of the right extremity, ipsilateral violaceous spot, in addition to pain and paresthesia. Physical examination revealed longitudinal enlargement of the right lower limb, hyperpigmented nevus on the lateral aspect of the right leg and thigh extending to the ipsilateral buttock and atypical varicose veins. Venous Doppler ultrasound with linear transducer reported incompetence of the greater saphenous vein and supragenicular perforators. Surgical management was performed by saphenectomy, deformity correction and referral to dermatology for laser therapy for hyperpigmented nevus. The patient showed favorable clinical-surgical evolution with remission of the symptomatology that motivated her consultation.

A síndrome de Klippel-Trenaunay é uma malformação vascular complexa com uma incidência de 2 a 3 casos por 100.000 nascidos vivos. Clinicamente, apresenta uma tríade clássica: manchas vinho do porto, veias varicosas de localização atípica e hipertrofia óssea e de tecidos moles. Apresentamos o caso de uma paciente do sexo feminino, 33 anos, sem histórico patológico ou cirúrgico de importância, que consultou por aumento de volume do membro direito, mancha violácea ipsilateral, além de dor e parestesia. O exame físico revelou aumento longitudinal do membro inferior direito, nevo hiperpigmentado na face lateral da perna e coxa direitas, estendendo-se até a nádega ipsilateral e veias varicosas atípicas. Foi realizado ultrassom Doppler venoso com transdutor linear, que relatou incompetência da veia safena magna e das perfurantes suprageniculares. O tratamento cirúrgico foi realizado por meio de safenectomia, correção da deformidade e encaminhamento à dermatologia para terapia a laser para nevo hiperpigmentado. A paciente apresentou uma evolução clínico-cirúrgica favorável com remissão dos sintomas que a levaram à consulta.

Doppler Indices of the Fetal Middle Cerebral and the Umbilical Arteries in Pregnancies at High Risk Followed Up for Suspected Fetal Growth Restriction

Background: Fetal growth restriction is related to compromised perinatal outcomes. The screening and prevention tools for fetal growth restriction like Doppler indices in high-risk groups compared with general antenatal populations. An evaluation of the correlation between Doppler indices and placental weight and birth weight of the neonate at term pregnancy in high-risk pregnancies is essential. For the early detection of fetal growth limitations in high-risk pregnancies, sensitive screening techniques are few. Objectives: To determine the most accurate indicator for predicting a poor perinatal outcome or intrauterine growth restriction by comparing and correlating the modifications in Doppler ultrasound studies of fetal circulation in general pregnant women with those of high-risk patients both with and without intrauterine growth retardation. Study design: A cross-sectional research including 81 healthy pregnancies and 19 high-risk patients at 31–40 weeks of gestation was conducted. The pulsatility index (PI) of the middle cerebral artery (MCA), the umbilical artery (UA), and the MCA PI to UA PI ratio were all analyzed. We compared the Doppler indices’ mean values. Then these values were correlated with placental weight and birth weight of the offspring. Results: A significantly low birth weight and less fetoplacental ratio and placental coefficient ratio were found in high-risk cases than in normal pregnant women (P <0.05). A strong positive relationship was observed between the middle cerebral artery pulsatility index and placental weight, while negative relationship between the pulsatility index of the middle cerebral artery and the Feto-placental ratio (P < 0.05). In addition, a positive association was found between the pulsatility index of the middle cerebral artery and placental coefficient, whereas a negative correlation was observed between the Cerebro-placental ratio and Feto-placental ratio in high-risk cases (P <0.05). Conclusion: Low birth weight can be predicted using Doppler indices since there is a definite correlation between it and unfavorable perinatal outcomes.

Value of the strain ratio in the differential diagnosis of intraocular tumors by elastosonography: A retrospective case-control study

Purpose: To examine the role of the strain ratio in elastosonography for the differential diagnosis of common intraocular tumors such as choroidal melanoma, choroidal hemangioma, choroidal metastatic carcinoma, and retinoblastoma. Methods: This study included patients suffering from intraocular space?occupying lesions and who visited Beijing Tongren Eye Center of Beijing Tongren Hospital affiliated to Capital Medical University from June 2016 to March 2020. All patients underwent a physical examination, fundus examination with mydriasis, color Doppler ultrasonography, elastosonography, magnetic resonance imaging (MRI), and fundus angiography within 1 week. All patients were grouped as choroidal melanoma, choroidal metastatic carcinoma, retinoblastoma, choroidal hemangioma, and optic disk melanocytoma. A receiver operating characteristic (ROC) curve analysis was performed to assess the strain ratio for diagnosing malignant intraocular tumors. Results: A total of 155 patients (161 eyes) were recruited. The strain ratios measured were 39.59 ± 15.92 for choroidal melanoma, 36.85 ± 13.64 for choroidal metastatic carcinoma, 38.93 ± 17.27 for retinoblastoma, 13.42 ± 10.93 for choroidal hemangioma, and 3.84 ± 1.32 for optic disk melanocytoma. The strain ratios of the three malignant lesions were significantly higher than those of the two benign lesions (all P < 0.001). The area under the ROC curve was 0.95 ± 0.028. The optimal cutoff point was 22.67, with 85.7% sensitivity and 96.4% specificity. Conclusion: There were significant differences in elasticity between the malignant and benign intraocular tumors. The strain ratio using elastosonography could serve as an important auxiliary examination to distinguish between benign and malignant intraocular tumors

Acercamiento teórico al uso de la imagenología en el diagnóstico temprano de la artritis reumatoide / Theoretical approach to the use of imaging in the early diagnosis of rheumatoid arthritis

La artritis reumatoide es una enfermedad progresiva, con manifestaciones clásicas y tempranas como es la afectación de las articulaciones pequeñas de las manos y los tobillos. Se realizó una revisión bibliográfica de los documentos publicados entre 2017 y 2022. Se realizó una lectura preliminar de 37 artículos que cumplían con los criterios de inclusión, y finalmente se seleccionaron 23 artículos, de los cuales se tomó el contenido de mayor importancia. La ecografía es una técnica fiable y más sensible que la exploración clínica en el estudio de la enfermedad músculo-esquelética, pues permite una exploración multiplanar y dinámica, lo que resulta en un diagnóstico más exacto. La técnica Doppler constituye un complemento útil en el seguimiento de estos pacientes. Esta enfermedad es recurrente en las consultas de Reumatología, por tanto, en su valoración inicial, la utilidad de los medios diagnósticos, especialmente la ecografía, tiene gran importancia.

Rheumatoid arthritis is a progressive disease, with classic and early manifestations such as involvement of the small joints of the hands and ankles. We conducted a bibliographic review of the documents published between 2017 and 2022. A preliminary reading of 37 articles that met the inclusion criteria was carried out, and 23 articles were finally selected, from which the most important content was taken. Ultrasound is a more sensitive and reliable technique than clinical examination for the study of musculoskeletal disease, since it allows a multiplanar and dynamic examination, which results in a more accurate diagnosis. Doppler technique is a useful complement in the follow-up of these patients. This disease is recurrent in Rheumatology consultations, that's why in its initial assessment, the usefulness of diagnostic means, especially ultrasound, is of great importance.

Role of P Wave Duration and Tissue Doppler Imaging as Predictive Indicators for Paroxysmal Atrial Fibrillation in Hypertensive Patients

Background: Atrial fibrillation (AF) is the most prevalent chronic arrhythmia in the heart. AF accounts for one-third of rhythm disorder hospitalizations. AF increases profoundly the risk of stroke, heart failure, and death. This study used P-wave and transthoracic echocardiography with tissue Doppler imaging (TDI) to determine paroxysmal AF predictors in hypertensive individuals. Methods: This case control study was performed on 100 hypertensive adult patients. They were classified into two equal group: Group I included hypertensive patients diagnosed to have paroxysmal AF. Group II (control group) included hypertensive patients with normal sinus rhythm. All subjects were subjected to electrocardiographic and conventional and tissue Doppler Imaging measurements. Results: Pmax had significantly increased in PAF patients compared to sinus rhythm patients. PAL, PAR, PAI, LR, LI and IR had significantly increased in PAF patients compared to sinus rhythm patients. In Multivariate logistic regression analysis, Pmax, PAL, PAI, PAR, LR, LI and IR were found to be independent predictors for PAF. Therefore, Pmax, PAL PAI, PAR, LR, LI and IR were found to be significant predictors for PAF. Best cut-off values for Pmax, PAL, PAI, PAR, LR, LI and IR were: (118, 81, 61, 49.9, 34, 20 and 16 ms) with sensitivity (76, 96, 96, 88, 82, 86 and 77.5 ), specificity (84, 100, 98, 92, 78, 82 and 76) and the AUC of (0.850, 0.979, 0.987, 0.961, 0.836, 0.891 and 0.798) respectively. Conclusions: Electrocardiographic P-wave analysis and echocardiographic TDI may identify hypertension patients at risk for paroxysmal AF, since the combination of Pmax and TDI may help in predicting the development of AF in hypertensive individuals.

Assessment of Left Ventricular Diastolic Dysfunction in Cases with Liver Cirrhosis

Background: Cirrhosis is a long-term inflammatory process of hepatic tissue condition that mainly affects people aged 50 to 60. This study aims to assess Left ventricular diastolic dysfunction (LVDD) in cases with cirrhotic liver by conventional, tissue Doppler and two-dimensional speckle tracking echocardiography to clarify the correlation between the severity of cirrhotic liver and LVDD. Methods: A prospective case-control research involved 100 adult cases with confirmed HCV and HBV. Cases were divided into 4 equal group: Group A: Child A cases, group B: Child B cases, group C: Child C cases and group D (Controls): healthy non-hepatic subjects of the same age and sex who have normal blood pressure, nonsmoking participants with no further concomitant problems. Results: Number of cases with LVDD had a statistical noticeable increase in Child A, B, and C (p =0.004, <0.001, and <0.001 respectively. LAVi had a statistical noticeable increase in Child C / B (p =0.013 and p =0.014). Conclusion: Left atrial volume index (LAVi) had a statistical noticeable increase in Child C / B in comparison to the controls but E m, E l were statistical noticeable lower in Child C / B. /E had a statistical noticeable increase in Child C group, LVSRe had a statistical noticeable decrease in Child C group but it was insignificantly different across Child A / B/ C and controls and across Child B / C and controls.